I 


TICS    AND    THEIR    TREATMENT 


TICS*     AND 

THEIR   TREATMENT 

Br    HENRY    MEIGE    AND    E.    FEINDEL 


With  a  Preface  by 

Professor    Brissaud 


TRANSLATED  and  EDITED,  with  a  CRITICAL  APPENDIX 

BY    S.   A.    K.    WILSON,    M.A.,    M.B.,   B.Sc. 

Resident  Medical  Officer,  National  Hospital  for  the  Paralysed  and  Epileptic. 
Queen  Square,  London 


NEW    YORK 
WILLIAM    WOOD    AND    COMPANY 

1907 


COPYRIGHTED  1907   BY  SIDNEY   APPLETON 

ALL  RIGHTS  RESERVED 
PRINTED   IN   GKEAT   BRITAIN 


fit 


B  P?  A 

*»T",    ••    ,    M.r'* 
SAN!  A   «»•'  ••../IHJA 


PREFACE 

could  be  less  scientific  than  the  establish- 
"+**  ment  of  a  hierarchy  among  medical  problems 
based  on  the  relative  severity  of  symptoms.  Prognosis 
apart,  there  can  be  no  division  of  diseases  into  major 
and  minor. 

Hitherto  no  great  importance  has  been  attached 
to  those  reputedly  harmless  "  movements  of  the  nerves  " 
known  as  tics :  an  involuntary  grimace,  a  peculiar 
cry,  an  unexpected  gesture,  may  constitute  the  whole 
morbid  entity,  and  scarcely  invite  passing  attention, 
much  less  demand  investigation.  Yet  it  is  the  outcome 
of  ignorance  to  relegate  any  symptom  to  a  secondary 
place,  for  we  forget  that  difficult  questions  are  often 
elucidated  by  apparently  trivial  data.  A  fresh 
proof  of  the  truth  of  this  remark  is  to  be  found  in 
P--  the  accompanying  volume,  to  which  MM.  Meige  and 
Feindel  have  devoted  several  years  of  observation. 

To    begin    with,  they    must    be   congratulated  on 

having  done  justice   to   the  word  tic.     No   doubt    its 

origin  is   commonplace  and   its   form   unscientific,  but 

^r    its   penetration  into   medical   terminology   is  none  the 

aP    less    instructive.      If    popular    expression    sometimes 

r>    confounds  where  experts  distinguish,  in   revenge   it  is 

^2    frequently  so  apt  that  it  forces  itself  into  the  vocabulary 


vi  PREFACE 

of  the  scientist.  In  the  case  under  consideration  Greek 
and  Latin  are  at  fault.  The  meaning  of  the  word  tic 
is  so  precise  that  a  better  adaptation  of  a  name  to 
an  idea,  or  of  an  idea  to  a  name,  is  scarcely  conceivable, 
while  the  fact  of  its  occurrence  in  so  many  languages 
points  to  a  certain  specificity  in  its  definition. 

Yet  till  within  recent  years  tic  had  all  but  dis- 
appeared from  the  catalogue  of  diseases.  A  closer 
study  of  reflex  acts,  however,  has  led  to  the  grouping 
together  of  various  clonic  convulsions  of  face  or  limbs, 
including  "  spasms "  on  the  one  hand,  and,  on  the 
other,  conditions  of  an  entirely  different  nature,  for 
which  the  term  "  tics "  ought  to  be  reserved.  The 
separation  of  "  tics  "  from  "  spasms,"  properly  so  called, 
has  been  the  object  of  various  experiments  and 
observations  made  by  the  authors  and  by  myself,  the 
practical  value  of  which  is  evidenced  by  their  dis- 
closure of  efficacious  therapeutic  measures. 

Among  the  confused  varieties  of  spasm,  clonus, 
hyperkinesis,  etc.,  it  is  impossible  not  to  recognise 
the  obvious  individuality  of  certain  motor  affections — 
certain  movements  of  defence,  of  expression,  of 
mimicry,  certain  gestures  more  or  less  co-ordinated 
for  some  imaginary  end — all  readily  distinguishable/! 
from  spasms,  fibrillary  contractions,  and  choreiform/ 
or  athetotic  movements.  It  is  only  logical  to  attribute 
a  somewhat  more  complex  origin  to  these  varying 
gestures,  in  which  the  influence  of  the  will,  however 
unperceived  in  the  end,  is  always  to  be  detected  at 
the  beginning. 

While  some  convulsions  and  spasms  are  the  product 
of  special  changes  in  muscle  fibre,  or  motor  nerve,  or 


PREFACE  vii 

spinal  cord,  in  medulla,  pons,  or  basal  nuclei,  the 
synergic  and  co-ordinated  muscular  contractions  of 
tic  imply  cortical  intervention.  The  will  may  not  , 
play  a  conscious  role  therein,  but  the  cortex  alone  is 
capable  of  initiating  such  acts.  What  part  does  it 
take  in  their  genesis? 

For  an  instance,  a  simple  blinking  of  the  eyelids 
may  form  a  tic.  Considered  in  itself,  it  is  a  movement 
of  defence  against  dust  or  light ;  but  in  the  absence 
of  irritation  it  becomes  meaningless.  How  then  are 
we  to  explain  the  abruptness  and  intensity  of  con- 
traction of  the  orbicularis  palpebrarum,  and  of  this 
muscle  alone  ?  If  it  were  due  to  stimulation  at  some 
point  on  the  reflex  facial  arc,  other  facial  muscles  ought 
to  be  involved  ;  if  referable  to  isolated  excitation  of  the 
orbicularis  filaments  of  the  facial  nerve,  why  is  the 
contraction  bilateral  ?  It  is  evident  we  are  dealing  here 
not  with  a  simple  reflex  of  bulbar  origin,  but  with  a 
movement  at  once  premeditated  and  purposive,  and  it  is 
this  purposive  element,  presupposing,  as  it  does,  co-y 
ordination  of  contraction,  that  indicates  the  cortical 
nature  of  the  phenomenon.  Such  co-ordinated  move- 
ments, however  causeless  and  inopportune  they  may 
appear,  cannot  be  identified  with  mere  pathological 
reflexes  or  spasms.  They  are  tics. 

Such,  since  the  days  of  Trousseau  and  Charcot,  has 
been  the  teaching  of  the  Paris  School  of  Medicine. 
Nevertheless,  confusion  remains,  and  in]«many  text- 
books the  unfortunate  sacrifice  of  analytical  accuracy 
to  a  premature  desire  for  the  schematic  classification 
of  disease  has  not  tended  to  lessen  it. 

The  authors   of  this  volume   have   been  resolute  in 
their  reference   of  the   pathogeny   of  tic  to  a  ^mental 


viii  PREFACE 

process.  It  is  true,  recognition  of  the  psychological 
aspect  of  the  affection  is  ready  enough  where  the 
tic  corresponds  or  is  superadded  to  other  "  episodic 
stigmata  of  degeneration " ;  but  the  task  is  infinitely 
more  delicate  should  the  sole  indication  of  an  abnormal 
psychical  state  be  the  tic  itself.  Even  in  these  cases 
examination  always  reveals  insufficiency  of  inhibition, 
to  which  are  due  the  inception  and  the  persistence 
^  of  many  "bad  habits."  "We  can  thus  appreciate  the 
role  of  habit  in  the  evolution  of  tics,  and  recognise 
the  analogy  they  offer  to  all  functional  acts.  A  tic 
is  frequently  nought  else  than  the  ill-timed  and  in- 
apposite execution  of  some  function.  We  may  even 
conceive  a  sort  of  functional  tic  centre,  formed  by 
nerve  elements  corresponding  to  the  functional 
grouping  of  the  muscles  involved  in  the  tic.  In 
advanced  cases  we  may  imagine  some  sort  of  hyper- 
trophy of  this  functional  centre,  which  may  be 
reduced  by  suppression  of  function — that  is  to  say,  by 
certain  methods  of  immobilisation. 

This  is  the  secret  of  the  treatment  of  tics,  and 
to  ignore  it  would  be  disastrous.  As  a  matter  of 
fact,  tic  is  not  merely  a  neurosis,  but  a  psychoneurosis, 
or,  to  be  more  exact,  a  psychomotor  encephalopathy. 
The  degeneration  whose  first  manifestation  in  a  child 
is  the  development  of  a  tic  may  reveal  itself  later 
by  more  disquieting  signs.  This  word  "  degeneration  " 
is  employed  either  too  indefinitely  or  too  explicitly 
by  those  who  are  ignorant  of  its  true  meaning  in 
medicine.  To-day  the  physician's  diagnosis  is  often 
anticipated  by  the  parents,  who  are  willing  to  own 
:!  their  child  "  nervous  "  because  of  his  tic ;  but  they  are 
not  so  ready  to  admit  he  has  a  tic  because  he  is 


PREFACE  ix 

nervous,  as  they  would  infer   immediately   that   they  ]  ^  ' 
have    begotten    a     degenerate.      The    consolation    of  / 
"  superior  degeneration "   does  not  exclude   a   certain 
degree  of  humiliation. 

No  doubt  superficial  study  is  content  to  characterise 
children  thus  afflicted  by  the  simple  epithet  "  nervous," 
on  the  ground  that  their  tic  does  not  constitute  a 
menace  to  life.  But  a  tic  in  itself  can  never  be  a  ^ 
negligible  quantity.  The  more  it  is  repeated  the  more 
inveterate  it  becomes,  and  the  greater  the  likelihood 
of  its  becoming  generalised ;  at  the  same  time  the 
influence  of  the  neuropathic  diathesis  is  intensified. 
An  analogy  might  be  drawn  between  the  tics  and  chorea. 
Prognosis,  even  in  a  mild  case  of  adult  chorea,  should 
always  be  guarded,  inasmuch  as  once  the  ordinary  limits 
of  the  duration  of  the  disease  are  over-stepped,  we  find 
ourselves  face  to  face  with  the  dreaded  chronic  variety. 

The  same  attitude  might  be  adopted  in  reference 
to  the  distressing  neurosis  described  by  Charcot  and 
Grilles  de  la  Tourette  as  the  "disease  of  the  tics," 
which  is  no  more  than  the  superlative  expression 
of  a  neuropathic  and  psychopathic  disposition  entirely 
akin  to  that  favouring  the  development  of  the  most 
harmless  tic.  Its  earliest  exhibition  is  a  series  of 
apparently  insignificant  bizarre  convulsions;  but  its 
indefinite  prolongation,  its  gradual  involvement  of  one 
limb  after  another,  its  association  with  grave  mental 
symptoms,  and  its  frequent  termination  in  dementia, 
are  reason  enough  for  eyeing  the  first  little  premonitory 
tic  with  mistrust,  and  combating  it  with  vigour. 

From  the  motor  aspect  a  tic  is  only  a  "  bad  habit," 
and  the  checking  of  bad  habits,  especially  in  the  pre- 
disposed, must  be  our  goal  from  the  outset.  And, 


x  PREFACE 

should  we  succeed,  there  will  be  reason  for  congratula- 
tion, not  on  the  happy  issue  of  appropriate  treatment 
for  a  particular  tic,  but  because  the  result  is  a  step 
towards  the  habit  of  correcting  bad  habits.  Reinforce- 
ment of  the  will  is  the  prime  therapeutic  indication, 
but  the  physician  has  no  need  to  resort  to  mysterious 
subterfuges  or  occult  practices;  let  him  borrow  the 
virtues  of  the  successful  teacher.  The  amelioration 
consequent  on  this  procedure  is  seen  not  only  in  the 
recovery  of  lost  aptitude  for  work,  but  also  in  the 
simultaneous  restoration  of  self-confidence  and  will- 
power in  patients  who  had  appeared  deprived  of  them 
for  ever.  The  treatment  of  tic  is  evidence  of  its 
nature  and  curability.  Since  1893  MM.  Meige  and 
Feindel  have  subjected  their  cases  to  the  educational 
discipline  of  systematised  movement  and  of  immobilisa- 
tion. In  contrast  to  the  tendency  of  ordinary  exercises  to 
render  certain  useful  acts  automatic,  this  method  aims  / 
at  the  suppression  of  automatic  acts  that  have  become 
useless.  The  development  of  the  general  principles 
of  the  method,  as  well  as  an  exposition  of  recent 
modifications  and  their  application  to  particular  cases, 
will  be  found  in  the  volume.  Suffice  it  here  to  say 
that  the  results  have  been  favourable  enough  to 
discountenance  the  prevalent  idea  of  the  incurability 
of  tic,  and  to  prove  that  persistence  in  treatment,  as  has 
been  demonstrated  in  many  other  neuroses,  will  assuredly 
be  crowned  with  success.  Common  misconception 
represents  therapeutics  as  helpless  in  the  presence  of 
nervous  disease ;  but  if  the  doctor  may  count  on  the 
collaboration  of  his  patient,  he  has  no  right  to  despair. 
I  should  like,  in  closing,  to  be  allowed  to  praise  the 
authors'  production ;  but  I  can  do  so  only  under  great 


PREFACE  xi 

reserve,  for  after  so  many  years  of  co-operation  I  can 
no  longer  distinguish  the  work  of  MM.  Meige  and 
Feindel  from  my  own.  I  think,  however,  that  from 
many  points  of  view  the  book  which  they  have  written 
is  a  most  useful  one. 

E.  BRISSAUD. 


AUTHORS'    PREFACE 

OUR  object  in  publishing  these  studies  has  been 
twofold:  first,  to  make  known  various  facts  of 
clinical  observation,  which  will  always  possess  at  the 
least  an  intrinsic  value;  secondly,  to  endeavour  to 
assign  to  the  tics  their  due  place  among  the  numerous 
motor  affections  consequent  on  nervous  or  mental 
disease.  With  this  end  in  view  we  sought  to  free 
ourselves  of  preconceived  notions,  avoiding  at  the  same 
time  the  other  extreme  of  eclecticism.  Independently 
we  have  been  led  to  adhere  to  the  doctrine  hallowed 
by  the  authority  of  Chare ot,  and  since  advocated  by 
Professor  Brissaud — a  doctrine  that  seems  to  us  to  be 
in  harmony  with  accepted  clinical  data. 

We  have  thought  it  advisable  to  indicate,  by  the 
way,  more  than  one  misconception  whose  perpetuation 
is  but  a  stumbling-block  in  the  path  of  progress. 

Since  the  eighteenth  century  the  word  tic  has  faced 
the  perils  of  definition  many  a  time,  and  has  as  often 
all  but  succumbed.  The  limits  of  its  application  have 
been  alternately  enlarged  and  narrowed  to  an  excessive 
degree;  its  original  signification  has  been  so  obscured 
that  the  inclination  to-day  is  either  to  hesitate  in  the 
use  of  the  word  at  all,  or  to  employ  it  indiscriminately 
through  ignorance  of  its  real  meaning.  But  if  its 
interpretation  be  not  specified,  everything  that  is  said 


xiv  AUTHORS'    PREFACE 

or  written  on  the  subject  will  remain  fatally  open  to 
dispute.  Want  of  precision  in  words  leads  inevitably 
to  confusion  of  ideas  and  endless  misunderstanding. 
In  this  respect  the  word  tic  is  a  great  culprit;  its 
promiscuous  use  implies  looseness  in  its  connotation — 
a  fruitful  source  of  controversies  which,  when  all  is 
said  and  done,  are  nothing  more  than  regrettable  quid 
pro  quos.  On  fundamental  points  there  is  almost 
complete  unanimity  of  opinion ;  any  divergence  is 
purely  superficial,  and  to  be  ascribed  to  disagreement 
in  terms. 

Hence  it  has  seemed  to  us  essential  to  adopt  a 
vocabulary,  and  to  employ  any  term  only  after  clearly 
particularising  the  sense  we  attribute  to  it.  Our  verbal 
conventions  will  not  meet  with  universal  acceptance, 
it  may  be,  but  we  shall  be  the  first  to  abandon  them  if 
common  consent  assign  to  the  expressions  that  replace 
them  the  exact  shade  of  meaning  we  meant  to  convey. 

Our  work  will  not  be  superfluous  if  we  succeed  in 
allotting  to  the  word  a  definite  position  in  medical 
terminology,  or  if  any  information  we  have  amassed 
prove  of  service  to  future  observers.  And  should  we 
be  enabled  to  demonstrate  how  unmerited  is  the 
reputation  the  tics  enjoy  of  being  irremediable,  how 
they  may,  on  the  contrary,  be  mitigated  and  sometimes 
even  cured  under  appropriate  treatment,  the  practical 
value  of  the  conclusion  will,  we  hope,  justify  the 
importance  we  have  attached  to  the  subject. 


7 


NOTE    BY  THE   TRANSLATOR 

/~\WING  to  the  kind  co-operation  of  M.  Meige,  it  has  been  possible  to 
^r  embody  in  this  English  version  of  Les  tics  et  leur  traitement  his 
latest  definitions  and  views,  as  expressed  in  his  monograph  Les  tics 
(July,  1905).  The  passages  thus  derived  are  enclosed  in  brackets.  In 
the  making  of  the  translation  some  of  the  clinical  cases  have  been 
slightly  abridged,  and  one  or  two  omitted.  The  Bibliography  has  been 
revised,  largely  supplemented,  and  brought  up  to  date.  In  a  short 
Appendix  reference  is  made  to  various  matters  in  regard  to  tic  on 
which  discussion  has  recently  centred,  subsequent  to  the  publication 
of  Meige  and  Feindel's  book.  Indices  of  names  and  of  subjects  have 
been  added. 


CONTENTS 


PAGE 

PREFACE  BY  PROFESSOR  BRISSAUD     .  .  .  .  V 

AUTHORS'  PREFACE xiii 

NOTE  BY  THE  TRANSLATOR  XV 


CHAPTER  II 

HISTORICAL  ...  •  .25 

CHAPTER  III 

THE  PATHOGENY  OF  TIC  .  .  .36 

TIC  AND  SPASM 

TIC  AND    MOTOR    REACTIONS ;   REFLEX,    CO-ORDINATED,   FUNCTIONAL, 

AUTOMATIC,   AND  VOLUNTARY  ACTS 
TIC  AND  CO-ORDINATION 
THE  GENESIS  OF  TIC 
TIG  AND  WILL 
TIC  AND  HABIT 
TIC  AND  IDEA 
TIC  AND  CONSCIOUSNESS 
TIC  AND  POLYGON 
TIC  AND  FUNCTION 

xvii  6 


xviii  CONTENTS 

CHAPTER  IV 

PAGE 

THE  MENTAL  CONDITION  OF  TIC  SUBJECTS  ...         74 

CHAPTER  V 

THE  ETIOLOGY  OF  TICS 96 

CHAPTER  VI 
PATHOLOGICAL  ANATOMY 108 

CHAPTER    VII 

STUDY  OF  THE  MOTOR  REACTION 118 

THE  TYPE  OF  MOTOR  REACTION — CLONIC  TIC  AND  TONIC  TIC 

INTENSITY  OF  THE  MOTOR  REACTION 

FREQUENCY  AND  RHYTHM— RHYTHMIC  TIC 

ATTACKS 

LOCALISATION  OF  THE  MOTOR  REACTION— VARIABLE  TICS— FIXBD  TICS 

CHAPTER  VIII 

ACCESSORY  SYMPTOMS 134 

REFLEXES 

ELECTRICAL  REACTIONS 

VASOMOTOR  AND  SECRETORY  AFFECTIONS 

AFFECTIONS  OF  SENSATION 

CHAPTER  IX 

THE    DIFFERENT  TICS 142 

FACIAL  TICS — TICS  OF  MIMICRY 

TICS  OF  THE  EAR— AUDITORY  TICS 

TICS  OF  THE  EYES— NICTITATION  AND  VISION  TICS 

A.  EYELID  TICS 

B.  EYEBALL  TIOS 


CONTENTS  xix 


TICS  OF  THE  NOSE — SNIFFING  TICS 

TICS  OF  THE   LIPS— SUCKING   TICS 

TICS  OF  THE  CHIN 

TICS  OF  THE  TONGUE — LICKING  TICS 

TICS  OF  THE  JAWS— BITING  TICS — TICS  OF   MASTICATION 

MENTAL  TRISMUS 

TICS  OF  THE  NECK— NODDING  AND  TOSSING  TICS— TICS  OF  AFFIRMA- 
TION, NEGATION,  AND  SALUTATION 

MENTAL  TORTICOLLIS 

TICS  OF  THE  TBUNK 

TICS  OF  THE  ARM   AND  OF  THE   SHOULDER 

TICS  OF  THE  HANDS— SCRATCHING  TICS 

TICS  AND  WRITING 

TICS  OF  THE  LOWER   EXTREMITIES— WALKING  AND  LEAPING  TICS 

SPITTING,  SWALLOWING,  AND  VOMITING  TICS — TICS  OF  ERUCTA- 
TION AND  OF  WIND  SUCKING 

TICS  OF  RESPIRATION— SNORING,  SNIFFING,  BLOWING,  WHISTLING, 
COUGHING,  SOBBING,  AND  HICCOUGHING  TICS 


CHAPTER  X 
TICS  OF  SPEECH 206 

ECHOLALIA 
COPROLALIA 


CHAPTER  XI 

THE   EVOLUTION   OF  TICS         ....  .      221 

DISEASE  OF  GILLES   DE  LA  TOURETTE 
VARIABLE   CHOREA  OF   BRISSAUD 


CHAPTER    XII 
ANTAGONISTIC   GESTURES   AND   STRATAGEMS       .  .  .236 

CHAPTER  XIII 

THE    COMPLICATIONS    OF   TICS  .  .  •  .242 


XX 


CHAPTER   XIV 

MM 

THE      RELATION       OF      TICS      TO      OTHER      PATHOLOGICAL 

CONDITIONS 245 

TICS  AND  HYSTERIA 
TICS  AND  NEURASTHENIA 
TICS   AND  EPILEPSY 
TICS— INSANITY— IDIOCY 
THE  TICS   OF   IDIOTS 


CHAPTER    XV 

THE  DISTINCTIVE  FEATURES  OF  TICS  ....      260 

CHAPTER   XVI 

DIAGNOSIS 264 

TICS  AND  STEREOTYPED  ACTS 
TICS  AND  SPASMS 

A.  TIC  OR  SPASM  OF  THE  FACE 

B.  TIC  OR  SPASM  OF  THE  NECK— TORTICOLLIS  TIC  AND  TORTI- 
COLLIS SPASM 

TICS  AND  CHOREAS 

A.  SYDENHAM'S  CHOREA 

B.  HUNTINGTON'S  CHOREA 

C.  HYSTERICAL  CHOREA 

D.  ELECTRIC   CHOREA,    BERGERON'S   CHOREA,   DUBINl's  CHOREA, 
FIBRILLAHY  CHOREA  OF  MORVAN 

TICS  AND  PARAMYOCLONUS  MULTIPLEX — TICS  AND  MYOCLONUS 

TICS  AND  ATHETOSI8 

TICS  AND  TREMORS 

TICS  AND  PROFESSIONAL  CRAMPS 


CHAPTER   XVII 

PROGNOSIS    .....  293 


CONTENTS  xxi 

CHAPTER  XVIII 

PAOI 

THE  TEEATMENT  OF  TICS 298 

THE  CURABILITY  OF  TIC8 

MEDICINAL  TREATMENT 

DIET— HYGIENE— HYDROTHERAPY 

MASSAGE — HEOHANOTHERAPY 

ELECTROTHERAPY 

SUGGESTION 

SURGICAL  TREATMENT 

ORTHOPEDIC  TREATMENT 

CHAPTER    XIX 

TREATMENT  BY  RE-EDUCATION 315 

MIRROR   DRILL 
REST  IN  BED 
ISOLATION 
PSYCHOTHERAPY 


APPENDIX 346 

BIBLIOGRAPHY         ..";.' 351 

INDEX    OF   NAMES 380 

INDEX    OF   SUBJECTS  384 


CHAPTER    I 

THE   CONFESSIONS   OP   A   VICTIM   TO   TIC 

AT  the  time  when  the  plan  of  our  book  was  being 
sketched  we  decided  to  introduce  the  subject 
with  several  characteristic  clinical  documents,  since  it 
appeared  to  us  indispensable  to  preface  our  definitions 
with  an  illustration  of  the  type  of  affection  and  of 
patient  that  we  had  in  view.  The  choice  was  rather 
bewildering  at  first ;  but  towards  the  close  of  1901 
one  of  us  was  put  into  communication  with  an  in- 
dividual who  is  a  perfect  compendium  of  almost  all 
the  varieties  of  tic,  and  whose  story,  remarkable  alike 
for  its  lucidity  and  its  educative  value,  forms  the 
most  natural  prelude  to  our  study.  The  history  is  / 
neither  a  fable  nor  an  allegory,  but  an  authenticated  * 
and  impartial  clinical  picture,  whose  worth  is  enhanced 
by  no  less  genuine  facts  of  self -observation. 

0.  may  be  said  to  constitute  the  prototype  of  the 
sufferer  from  tic,  for  his  grandfather,  brother,  and 
daughter  have  all  been  affected,  and  he  himself  has  not 
escaped.  His  grandmother  and  grandfather  were  first 
cousins,  and  the  latter,  in  addition  to  being  a  stammerer, 
developed  tics  of  face  and  head ;  his  brother  stammers 
too,  while  both  his  sister  and .  his  daughter  have  facial 

I 


2  TICS  AND    THEIR    TREATMENT 

tics,  and  one  of  his  sons  was  afflicted  with  asthma  as 
a  youth.  The  family  history  therefore  more  than  con- 
firms the  existence  of  a  grave  neuropathic  heredity,  an 
unfailing  feature  in  cases  of  tic. 

O.'s  fifty-four  years  lie  lightly  on  him.  His 
physique  and  general  health  are  excellent,  and  devotion 
to  bodily  exercise  and  outdoor  sports  has  enabled  him 
to  maintain  a  vigour  and  an  agility  above  the  average ; 
nor  is  his  intellectual  activity  any  less  keen. 

His  earliest  tics — simple  facial  grimaces  and  move- 
ments of  the  head — made  their  appearance  when  he 
was  eleven  years  old ;  notwithstanding,  his  recollection 
of  their  mode  of  onset  is  very  exact. 


I    have   always   been   conscious   of  a   predilection  for  imitation.      A 
curious  gesture   or   bizarre   attitude   affected   by  any  one   was    the   im- 
mediate signal   for   an   attempt   on   my  part  at  its  reproduction,  and  is 
J    still.     Similarly   with   words  or   phrases,    pronunciation  or  intonation,  I 
was  quick  to  mimic  any  peculiarity. 

When  I  was  thirteen  years  old  I  remember  seeing  a  man  with  a 
droll  grimace  of  eyes  and  mouth,  and  from  that  moment  I  gave  myself 
no  respite  until  I  could  imitate  it  accurately.  The  rehearsals  were  not 
prolonged,  as  a  matter  of  fact,  and  the  upshot  was  that  for  several  months 
I  kept  repeating  the  old  gentleman's  grimace  involuntarily.  I  had,  in 
short,  begun  to  tic. 

In  my  fifteenth  year  I  was  at  school  with  two  boys  whose  hair  was 
rather  long,  and  who  had  acquired  the  habit  of  tossing  it  back  by  an 
abrupt  shake  of  the  head.  It  is  true  I  cannot  recollect  endeavouring  to 
ape  this,  but  in  any  case  it  was  at  the  same  time  that  I  found  myself 
exhibiting  an  identical  gesture,  and  I  have  little  doubt  it  is  the  source 
of  one  of  the  tics  from  which  I  suffer  at  present. 

I  enlisted  at  the  commencement  of  hostilities  in  1870,  and  had  already 
begun  my  military  instruction,  when  a  personal  review  of  the  company 
was  made  by  a  new  colonel.  As  he  passed  he  came  to  a  sudden  halt 
before  me,  and  proceeded  to  harangue  me  on  my  far  from  military 
bearing  5  but  his  invective  had  no  other  effect  than  to  aggravate  my 
facial  contortions,  and  the  affair  might  have  proved  serious  enough  for 
me  had  not  my  captain  come  to  the  rescue  and  explained  the  involuntary 
nature  of  the  spasms.  The  colonel,  however,  would  have  none  of  them 
and  after  a  fortnight's  sojourn  in  hospital  I  was  discharged  for  "  choreic 
movements  of  the  face." 


THE   CONFESSIONS  OF  A    VICTIM  TO   TIC    3 

O.'s  tics  were  at  the  first  confined  to  the  eyes 
and  lips,  but  others  were  not  long  in  appearing.  He 
happened  to  be  out  one  day  for  a  walk  with  his  sister 
during  a  snowstorm,  and  a  flake  entering  his  nostril  made 
him  sneeze  and  sniff  half  a  dozen  times.  Long  after 
the  snow  had  ceased  falling  and  the  tickling  sensation 
had  vanished  he  repeated  the  performance,  till  it  passed 
into  a  sniffing  tic  that  continued  for  some  months. 
His  sister  thoughtlessly  set  herself  to  mimic  him,  and 
speedily  evolved  an  identical  tic,  which  still  persists. 

In  their  turn,  neck  and  shoulders  were  implicated 
in  the  affection.  The  most  inveterate  of  all  his  tics 
is  a  somewhat  complex  twist  of  the  head,  whereby 
the  occiput  is  depressed  jerkily,  and  the  chin  advanced 
and  elevated,  occasionally  to  the  right,  though  more 
commonly  to  the  left.  Such  is  the  clonic  form  of  the 
tic,  at  once  frequent  and  obvious ;  but  it  may  assume 
a  tonic  form,  distinguished  by  an  almost  permanent 
retrocollic  displacement  of  the  head,  the  chin  being 
carried  in  the  air. 

If,  now,  we  approach  these  tics  in  greater  detail, 
we  notice,  first  of  all,  a  blinking  tic,  more  marked 
on  the  left  side.  Apart  from  abrupt  and  intermittent 
contractions  of  the  orbicularis,  which  close  the  eye 
completely  and  wrinkle  the  skin  in  the  neighbourhood, 
the  same  muscle  sometimes  passes  into  a  state  of 
tonic  contraction,  whereby  the  eye  remains  only  half 
open,  while  the  rest  of  the  face  is  in  repose,  and  so 
continues  for  a  minute  or  more.  Frontal  and  eyebrow 
tics  also  are  frequently  to  be  remarked. 

Of  his  own  accord  0.  has  supplied  us  with  a 
pathogenic  and  etiological  analysis  of  these  tics,  which 
for  accuracy  and  insight  is  truly  astonishing. 

A  large  number  of  my  head  and  face  movements  owe  their  origin 
to  the  annoyance  caused  me  by  my  seeing  the  tip  of  my  nose  or  of  my 
moustache  from  time  to  time.  The  former  organ  appears  to  make  a 


4  TICS  AND    THEIR    TREATMENT 

sort  of  screen  in  front  of  me,  to  avoid  which  I  turn  or  raise  my  head  : 
I  can  now  see  the  object  I  am  facing,  but  at  the  same  time,  naturally, 
I  see  my  nose  again  at  the  side,  whence  one  more  tilt  of  the  head,  and 
so  on.  I  am  well  enough  aware  how  nonsensical  all  this  is  ;  but  it  fails 
to  deter  me  from  my  desire  of  playing  at  hide-and-seek  with  my  nose. 
It  is  for  an  identical  reason  that  each  moment  finds  me  blinking  one  eye 
or  the  other,  or  both  5  I  wish,  and  yet  I  do  not  wish,  to  see  my  nose, 
and  so  I  bring  my  hand  up  to  cover  my  face.  Vain  delusion  !  for  if 
I  conceal  my  nose  thus,  it  is  my  hand  I  see  next,  and  I  escape  from 
Scylla  to  fall  into  Charybdis  ! 

Here,  then,  is  a  tic  springing  from  an  ordinary  visual 
impression.  Any  one  can  see  the  point  of  his  nose 
if  he  wishes,  but  it  does  not  come  in  his  way  should 
he  be  looking  at  something  else ;  whereas  our  patient 
divides  his  attention  between  the  end  of  his  nose  and 
the  object  of  his  regard,  and  his  volatile  will  passes 
lightly  from  one  to  the  other,  incapable  of  concentrating 
itself  on  either.  Force  of  repetition  changes  the 
voluntary  act  into  an  automatic  habit,  the  initial 
motive  for  which  is  soon  lost ;  and  the  patient  shows 
the  weakness  of  his  character  by  making  little  or  no 
effort  at  inhibition. 

Resort  to  a  pince-nez,  in  view  of  advancing  age, 
has  contributed  materially  to  the  elaboration  of  a 
host  of  absurd  jerky  movements,  from  which  more 
tics  have  been  recruited. 

No  sooner  have  I  put  on  my  pince-nez  than  I  long  to  alter  its  position 
in  innumerable  ways.  I  must  needs  push  it  down  or  raise  it  up,  must 
set  it  farther  on  or  farther  off;  sometimes  I  tax  my  ingenuity  in  attempts 
to  displace  it  by  tossing  my  head.  Instead  of  looking  tranquilly  through 
the  glasses,  my  eye  is  continually  attracted  by  the  rim,  some  point  on 
which  I  try  to  focus  or  to  get  into  a  line  with  the  object  at  which  I 
am  gazing.  I  want  to  see  the  object  and  the  pince-nez  at  the  same  time  ; 
as  soon  as  I  no  longer  see  the  former  I  wish  to  see  it  again,  and  similarly 
with  the  latter.  My  tics  upset  my  pince-nez,  and  I  have  to  invent  another 
tic  to  get  it  back  into  place.  The  absurdity  of  this  vicious  circle  does 
not  escape  my  observation,  and  I  know  I  am  its  author,  yet  that  cannot 
prevent  my  becoming  its  victim. 

When  the  pince-nez  is  not  in  use  I  toy  with  the  spring  or  with  the 


THE    CONFESSIONS  OF  A    VICTIM  TO   TIC    5 

cord,  and  a  day  seldom  passes  without  my  breaking  the  one  or  the  other. 
As  I  wear  spectacles  at  home  one  might  suppose  their  relative  stability 
would  check  my  tricks  ;  but  their  pressure  on  my  temples  and  ears  only 
serves  to  provoke  fresh  movements  in  a  search  for  comfort. 

And   so   the   thing   goes  on.      I  was  perfectly  well   aware  of  it   at 
first,  and  was  wont  to  imagine  it  was  remediable  ;  eventually,  however, 
these  grimaces  of  mine  took  place  without  any  attention  on  my  part,  and        / 
then   in  spite  of  it,  and  I  was  no  longer  their  master.     There  seem  to      / 
be  two  persons  in  me  :  the  one  that  tics,  the  son  of  the  one  that   does 
not,  is  an  enfant  terrible,  a  source  of  great  anxiety  to  his  parent,  who 
becomes  a  slave  to  his  caprices.     I  am  at  once  the  actor  and  the  spectator  ; 
and  the  worst  of  it  is,  the  exuberance  of  the  one  is  not  to  be  thwarted  by 
the  just  recriminations  of  the  other. 

In  his  accidental  discovery  of  a  "  crack "  in  his 
neck  originated  other  tics.  As  a  matter  of  fact,  these 
"  cracks "  do  exist,  and  can  be  heard  at  a  little 
distance ;  but  it  always  requires  a  brisk  toss  of  the 
head  to  elicit  them.  This  is  O.'s  account  of  their 
evolution : 

One  day  as  I  was  moving  my  head  about  I  felt  a  "  crack " 
in  my  neck,  and  forthwith  concluded  I  had  dislocated  something.  It 
was  my  concern,  thereafter,  to  twist  my  head  in  a  thousand  different  ways, 
and  with  ever-increasing  violence,  until  at  length  the  rediscovery  of  the 
sensation  afforded  me  a  genuine  sense  of  satisfaction,  speedily  clouded 
by  the  fear  of  having  done  myself  some  harm.  The  painlessness  of  the 
crack  "  induced  me  to  go  through  the  same  performance  many  and  many 
a  time,  and  on  each  occasion  my  feeling  of  contentment  was  tinged  with 
regret  :  even  to-day,  notwithstanding  that  I  ought  to  be  persuaded  of  the 
harmlessness  of  the  occurrence  and  the  inanity  of  the  manoeuvre,  I  cannot 
withstand  the  allurement  or  banish  the  sentiment  of  unrest. 

One  could  not  desire  a  more  lucid  exposition  of 
the  pathogeny  of  so  many  of  these  head-tossing  tics. 
The  fundamental  importance  of  the  psychical  element 
that  precedes  the  motor  reaction,  with  the  secondary 
psychical  reaction  in  its  turn,  the  impulse  to  seek  a 
familiar  sensation,  and  the  illogical  interpretation  of 
it  under  the  influence  of  a  tendency  to  nosophobia, 
are  all  admirably  illustrated  in  O.'s  description. 


6  TICS  AND    THEIR    TREATMENT 

In  addition  to  such  "  cracks "  as  are  perceptible  to 
others,  0.  is  conscious  of  various  bizarre  subjective 
sensations  that  he  refers  to  the  same  region — "  bruised," 
"  dragging,"  "  crackling  "  feelings,  not  at  all  dolorous, 
to  which  he  devotes  an  inordinate  share  of  his  attention. 
There  is  nothing  abnormal  about  these,  of  course  ;  not 
only  may  we  notice  them  in  ourselves,  but,  with  a  little 
effort,  we  may  even  reproduce  them.  Our  indifference 
to  their  presence  is  the  exact  opposite  of  the  interest 
they  arouse  in  the  patient's  mind  ;  his  fickle  will  is, 
for  no  adequate  motive,  concentrated  on  a  commonplace 
event,  and  on  this  slender  basis  delusions  are  fostered 
and  tics  are  shaped. 

The  insight  into  the  close  association  between  the 
state  of  the  mind  and  the  development  of  tic  yielded 
by  a  study  of  the  foregoing  narrative  will  enable  us 
to  appreciate  the  perspicacity  of  what  follows : 

I  suppose  that  we  who  tic  make  a  great  number  of  voluntary 
movements  with  the  deliberate  purpose  of  withdrawing  attention  from  the 
tics  we  already  exhibit  ;  but  step  by  step  they  become  so  habitual  that  they 
are  nothing  less  than  fresh  tics  appended  to  the  old.  To  dissemble  one  tic 
we  fashion  another. 

Certain  objects  become  for  us  what  might  be  called  para-tics.  Such, 
for  an  instance,  is  my  hat.  I  used  to  imagine  I  could  mask  all  my 
oddities  by  tilting  it  on  my  head.  I  used  to  carry  it  in  my  hand,  and  play 
with  it  in  every  conceivable  manner — to  the  advantage  of  the  hatter  solely, 
for  it  did  not  last  me  more  than  six  weeks.  .  .  .  We  are  our  own 
physicians  at  first :  the  discomfort  of  a  tic  is  an  urgent  reason  for  our 
seeking  to  compass  its  overthrow. 

For  years  it  was  O.'s  custom  when  out  walking 
to  clasp  his  hands  behind  his  back,  bend  his  body 
forward,  and  hold  his  chin  in  the  air,  and  this  habit 
explains  his  attitude  tic  of  to-day.  The  ludicrousness 
of  it  was  early  impressed  on  him,  but  instead  of 
adopting  the  obvious  solution  of  the  difficulty,  he  pro- 
ceeded to  devise  a  whole  series  of  intricate  measures 
to  regain  the  correct  position — measures  which  he 


THE   CONFESSIONS  OF  A    VICTIM  TO    TIC    7 

picturesquely  names  para-tics.  At  first  he  used  the 
curved  handle  of  his  cane  to  pull  on  the  brim  of  his 
hat,  and  so  depress  his  head ;  a  subsequent  modification 
consisted  in  putting  the  cane  under  his  chin  and 
pressing  down  on  it.  Each  of  these  subterfuges 
attained  a  degree  of  success,  and  that  in  spite  of  the 
fact  that  in  one  case  the  extensors,  and  in  the  other 
the  flexors,  of  the  head  were  being  resisted :  in  other' 
words,  each  was  efficacious  so  long  as  0.  chose  to 
consider  it  so. 

Eventually  their  serviceableness  dwindled,  and 
0.  conceived  the  plan  of  slipping  his  cane  between 
his  jacket  and  his  buttoned  overcoat  so  that  the  chin 
might  find  support  against  its  knob.  In  the  move- 
ments of  walking,  however,  contact  between  the  two 
was  never  maintained — each  was  for  ever  seeking  the 
whereabouts  of  the  other ;  and  while  it  mattered  little 
that  this  incessant  groping  and  jockeying  wore  out 
several  suits  and  the  lining  of  several  overcoats,  the 
more  serious  result  was  the  acquisition  on  O.'s  part 
of  the  habit  of  making  various  up-and-down  and  side- 
to-side  movements  of  his  head,  which  continued  to 
assert  themselves,  though  chin  and  cane  were  no  more 
in  proximity. 

It  was  not  long  ere  the  ceaseless  intrusion  of  his 
head  tics  drove  him  every  moment  in  search  of  a 
support  for  his  chin.  To  read  or  write  he  was  forced  to 
rest  it  on  a  finger,  or  on  his  fist,  or  hold  it  between 
two  fingers,  or  with  his  open  hand,  or  with  two  hands, 
although  the  distraction  provided  by  a  serious  occu-  * 
pation  sufficed  to  banish  the  impulse  and  stay  the  tics. 

A  day  came  when  application  of  the  hand  no  longer 
seemed  calculated  to  ensure  immobility  of  the  head, 
whereupon  he  hit  on  the  idea  of  sitting  astride  a 
chair  and  propping  his  chin  against  it.  This  idea 
had  its  day,  and  the  next  move  was  to  press  his  nose 


8  TICS  AND    THEIR    TREATMENT 

against  one  end  of  the  chair  back.  Each  successive 
stratagem  was  of  marvellous  promise  at  the  outset, 
but  its  inhibitory  value  rapidly  deteriorated  and  new 
plans  were  concocted. 

All  schemes  for  fixation  lose  their  virtue  through 
time,  but  they  may  be  abandoned  for  other  reasons, 
one  of  the  principal  of  which  is  the  development  of 
pain.  By  dint  of  rubbing  or  pressing  his  nose  or  his 
chin  on  the  knob  of  his  cane  and  the  back  of  his 
chair,  0.  has  produced  little  excoriations  and  sores 
on  the  parts  concerned,  the  pain  of  which  acts  as  a 
deterrent,  but  his  tics  and  para-tics  break  out  afresh 
whenever  it  has  gone.  The  game  has  been  carried 
to  such  an  extent  that  under  the  chin  and  at  the 
root  of  the  nose  there  have  appeared  actual  corns — 
strange  stigmata  of  one's  "profession." 

The  details  in  the  mental  process  are  similar  to 
what  has  been  already  noted : 

It  was  the  craving  to  keep  my  head  in  a  correct  position  that  in- 
duced the  habit  of  leaning  my  chin  on  something,  and  I  found  it 
essential  to  feel  the  contact  ;  familiarity,  however,  soon  ended  in  my 
failing  to  perceive  it,  and  a  new  movement  was  made  that  I  might  ex- 
perience the  sensation  once  more.  And  so  on  the  ball  rolled,  till  aug- 
mentation of  the  force  I  exerted,  under  a  constant  incitement  to  feel 
something  more  or  something  else,  resulted  in  the  formation  of  callosities 
on  nose  and  chin. 

In  this  way  factitious  wants  come  into  being,  which 
may  be  described  as  a  sort  of  parasitic  function  of 
which  the  patient  is  alike  the  creator  and  the  dupe. 

O.'s  therapeutic  ingenuity,  however,  could  not 
rest  satisfied  except  when  some  fresh  contrivance  was 
being  put  to  the  test.  Needless  to  say,  at  one  time  he 
experimented  with  the  stiff  collars  affected  by  some 
sufferers  from  mental  torticollis. 

At  the  commencement  I  used  to  wear  collars  of  medium  height, 
though  not  wide  enough  to  admit  my  chin.  An  attempt  to  obviate 


THE   CONFESSIONS   OF  A    VICTIM  TO    TIC    9 

the  difficulty  by  unbuttoning  my  shirt  and  bending  my  head  down  so 
as  to  keep  my  chin  in  the  opening  proved  abortive,  owing  to  the 
weakness  of  the  resistance,  so  I  purchased  much  higher  and  stiffer  ones, 
in  which  I  buried  my  lower  jaw  and  prevented  its  moving  at  all.  The 
success  of  this  method  was  transitory,  nevertheless,  for  however  stiffly 
they  were  starched,  the  collars  invariably  yielded  in  the  end  and 
presented  a  lamentable  aspect.  I  next  happened  on  the  fatuous  plan 
of  attaching  a  string  to  my  brace  buttons,  and  passing  it  up  under 
my  waistcoat  to  connect  it  with  a  little  ivory  plate  that  I  held  between 
my  teeth,  its  length  being  so  arranged  that  in  order  to  seize  the  plate 
I  had  to  lower  my  head.  Admirable  idea  !  I  soon  was  forced  to 
abandon  it,  however,  for  my  trousers  were  pulled  up  on  the  right 
in  a  way  that  was  as  grotesque  as  it  was  uncomfortable.  I  have  always 
had  a  weakness  for  the  principle  of  the  thing,  nevertheless,  and  even  to-day 
as  I  go  down  the  street  I  sometimes  catch  hold  of  the  collar  of  my  jacket 
or  vest  with  my  teeth  and  stroll  along  in  this  way.  At  home  it  is  the 
collar  of  my  shirt  that  acts  as  my  tether. 

The  retrocollic  attitude  that  0.  favours  seems  to 
have  had  the  further  effect  of  making  him  forget  how 
to  look  down.  There  is  no  impairment  of  any  of  the 
eye  movements,  but  he  has  considerable  trouble  in 
directing  his  gaze  downwards,  and  if  with  his  head 
in  the  normal  position  he  holds  a  book  below  the  level 
of  the  plane  of  his  eyes,  reading  is  more  arduous,  and 
after  a  little  time  impossible.  Yet  there  is  no  indication 
whatever  of  ocular  paresis ;  it  is  rather  a  sort  of  appre- 
hension from  which  he  suffers.  On  several  occasions 
we  have  remarked  a  synergy  of  function,  head  and 
eyes  moving  upward  in  unison. 

Our  patient's  category  of  tics  is  not  yet  exhausted, 
however.  He  has  been  afflicted  with  a  shoulder 
tic,  consisting  of  simultaneous  or  alternate  elevation, 
sometimes  of  other  movements,  and  always  with  some 
abduction  of  the  arms.  Frequent  execution  of  these 
actions  has  culminated  in  the  acquisition  of  the  faculty 
of  voluntarily  producing  a  rather  loud  "  crack  "  in  the 
shoulder  articulations,  which  thus  not  merely  originated 


10  TICS  AND    THEIR    TREATMENT 

in  a  tic,  but  supplies  an  ever-active  stimulus  for  its  repro- 
duction ;  in  its  occurrence  satisfaction  and  dissatisfac- 
tion are  blended  as  before.  At  the  present  moment  the 
impulse  to  this  particular  tic  is  in  abeyance,  and  he 
has  ceased  to  take  any  interest  in  the  "  crack,"  con- 
sidering it  a  trivial  society  accomplishment  of  no 
significance  or  danger,  analogous  to  voluntary  subluxa- 
tion  of  the  thumb,  or  to  the  curious  sounds  that  some 
people  are  fond  of  making  by  way  of  diversion. 

Again,  0.  has  been  a  martyr  to  a  leg  tic  of 
several  months'  duration.  "When  he  was  on  his  feet,  he 
learned  to  strike  his  right  heel  against  his  left  ankle, 
wearing  his  trouser  through  in  no  time,  and  ceasing 
only  with  the  development  of  a  painful  wound  over 
the  bone.  Once  it  was  healed,  however,  came  the 
deliberate  search  for  the  sensation  again,  and  the 
pleasurable  feeling  in  its  rediscovery. 

In  O.'s  case  the  inhibitory  influence  of  the  will 
on  his  tics  is  abundantly  manifest.  Should  he  find 
himself  in  the  company  of  one  from  whom  he  would 
fain  conceal  his  tics,  he  is  able  to  repress  them  com- 
pletely for  an  hour  or  two,  and  similarly  if  he  is  deep 
in  an  interesting  or  serious  conversation.  Nevertheless, 
the  desire  to  let  himself  go  obtrudes  itself  again,  and 
if  he  can  refrain  no  longer  he  will  invent  any  pretext 
for  leaving  the  room,  abandoning  himself  in  his  moment 
of  solitude  to  a  veritable  debauch  of  absurd  gesticula- 
tions, a  wild  muscular  carnival,  from  which  he  returns 
comforted,  to  resume  sedately  the  thread  of  the  inter- 
rupted dialogue. 

0.  is  fond  of  cycling,  and  while  at  first  the  atten- 
tion that  the  necessary  co-ordination  of  hands  and 
feet  demanded  proved  an  effective  barrier  in  the  way 
of  his  tics,  now  that  he  can  maintain  his  equilibrium 
automatically  his  head  assumes  its  favourite  attitude 
of  posterior  displacement.  His  devotion  to  a  game  of 


THE   CONFESSIONS  OF  A   VICTIM  TO  TIC    n 

billiards,  or  to  such,  exercises  as  fencing  or  rowing,  is 
never  interfered  with,  by  an  unruly  tic.  He  is  a  great 
fisher,  and  when  he  "  has  a  bite,"  or  is  expecting  one, 
he  will  remain  motionless  indefinitely;  his  tics  do  not 
hinder  him  from  preparing  his  bait  with  the  minutest 
care.  But  let  his  interest  in  his  prospective  catch  fade, 
let  the  fish  be  disinclined  to  "  take,"  and  there  will  be 
a  renewal  of  the  movements. 

In  his  sleep  they  one  and  all  disappear.  The  mere 
assumption  of  a  horizontal  position,  however,  no  longer 
suffices  to  bridle  them,  and  before  dropping  off  to 
sleep  he  passes  many  a  minute  in  seeking  comfort. 
The  rubbing  of  his  head  on  the  pillow,  the  rustling  of 
the  clothes,  disturb  and  exasperate  him,  and  he  turns 
in  this  direction  and  that  for  relief ;  yet  should  he  hear 
or  feel  nothing,  he  will  change  about  once  more  in 
the  search  for  a  sensation  or  a  sound.  Thus  has  it 
come  about  that  to  procure  slumber  he  has  adopted  the 
extraordinary  plan  of  lying  at  the  very  edge  of  the  bed 
and  letting  his  head  hang  over. 

The  series  is  not  yet  at  an  end. 

0.  exhibits  a  tic  of  the  inferior  maxilla.  He 
protrudes  and  retracts  his  jaw  alternately  in  his 
endeavour  to  elicit  cracking  noises  from  his  temporo- 
maxillary  articulations.  At  one  time  his  hands  used 
to  join  in  the  fray,  the  goal  being  to  overcome  the 
masseters  and  effect  a  sort  of  dislocation.  A  biting 
tic  ensued.  One  day  0.  was  alarmed  to  discover  two 
dark  patches  on  the  internal  aspect  of  the  cheeks, 
but  was  reassured  on  learning  from  his  sister — whose 
proclivities  lay  in  a  similar  direction — that  she  had 
noticed  the  same  in  her  own  case,  and  that  it  was  the 
result  of  constant  nibbling  at  the  buccal  mucous 
membrane. 

Nor  was   this  the    solitary   biting    tic.      Formerly 


12  TICS  AND    THEIR   TREATMENT 

a  pencil  or  a  pen-holder  used  to  be  unrecognisable 
at  the  end  of  twenty-four  hours,  and  the  handles  of 
canes  and  umbrellas  suffered  as  well.  To  obviate  the 
nuisance  he  entertained  the  unfortunate  idea  of  using 
metal  pen-holders  and  carrying  silver-mounted  walking- 
sticks;  but  his  teeth  failed  to  make  any  impression 
on  the  objects,  and  began  to  break  in  consequence. 
The  irritation  produced  by  a  small  dental  abscess 
proved  an  additional  source  of  mischief,  for  he  developed 
the  habit  of  trying,  with  finger,  cane,  or  pen-holder, 
to  shake  the  teeth  in  their  sockets,  and  was  finally 
compelled  to  have  the  incisors,  canines,  and  first  molars 
drawn.  Then  he  ordered  a  set  of  false  teeth — a  move 
that  afforded  a  new  excuse  for  a  tic.  Every  moment 
the  set  was  in  imminent  risk  of  being  swallowed,  so 
vigorously  did  his  tongue  and  lips  assail  it.  Fortunately 
such  an  accident  has  never  occurred,  although  he  has 
already  broken  several  sets.  Sometimes  he  would  be 
seized  with  an  insane  impulse  to  take  his  teeth  out,  and 
would  invent  the  flimsiest  pretext  for  retiring ;  the  set 
would  then  be  extracted  and  immediately  reinserted, 
to  his  complete  satisfaction  and  peace  of  mind. 

An  infinite  variety  of  scratching  tics  must  be  added 
to  the  number.  He  has  also  a  tic  of  phonation  dating 
back  to  his  fifteenth  year.  His  custom  was,  when 
learning  his  lessons  at  school,  to  punctuate  his  recital 
of  them  with  little  soft  expiratory  noises  that  may 
still  be  distinguished  to-day  among  a  host  of  other 
tics.  The  following  is  his  proffered  explanation  of  the 
pathogeny  of  this  "  clucking  "  tic : 

We  who  tic  are  consumed  with  a  desire  for  the  forbidden  fruit.  It  is 
when  we  are  required  to  keep  quiet  that  we  are  tempted  to  restlessness  ; 
it  is  when  silence  is  compulsory  that  we  feel  we  must  talk.  Now,  when 
one  is  learning  his  lessons,  conversation  is  prohibited,  the  natural  con- 
sequence being  that  he  seeks  to  evade  the  galling  interdict  by  giving 
rent  to  some  inarticulate  sound.  In  this  fashion  did  my  "  cluck  "  come 


THE  CONFESSIONS  OF  A    VICTIM  TO  TIC     13 

~^5 

into  being.  Moreover,  we  abhor  a  vacuum,  and  fill  it  as  we  may. 
Various  are  the  artifices  we  might  employ — such,  for  instance,  as  speaking 
aloud  ;  but  that  is  much  too  obvious,  and  does  not  satisfy  :  to  make 
a  little  grunt  or  cluck,  on  the  other  hand — what  a  comfort  in  a  tic  like 
that  ! 

We  need  not  smile  at  these  explanations,  for  they 
are  corroborated  by  the  facts  of  clinical  observation. 
Fear  of  silence  is  nothing  else  than  a  form  of  phobia, 
comparable  to  the  fear  of  open  spaces. 

O.'s  account  of  the  origin  of  his  tics  supplies 
further  evidence  of  the  mental  infantilism  of  those  with 
whom  we  are  at  present  concerned.  It  is  the  prerogative 
of  "  spoilt  children  "  to  wish  to  do  exactly  what  they 
are  forbidden  to  do.  They  seem  to  be  animated  by 
a  spirit  of  contrariness  and  of  resistance ;  and  if  in 
normal  individuals  reason  and  reflection  prevail  with  the 
.approach  of  maturity,  in  these  "  big  babies "  many  J 
traces  of  childhood  persist,  in  spite  of  the  march  of 
years. 

In  the  strict  sense  of  the  words  there  never  has 
been  any  echolalia  or  coprolalia  in  O.'s  case,  though 
it  has  happened  that  expressions  lacking  in  refinement 
have  escaped  him ;  but  he  never  has  been  consciously 
jet  irresistibly  urged  to  utter  a  gross  word.  The  sole 
vestige  of  anything  of  the  kind  is  a  sort  of  fruste 
coprolalia  that  consists  in  an  impulse  to  use  slang— an 
impulse  which  he  cannot  withstand  and  which  he  finds 
consolation  in  obeying. 

Some  additional  details  may  be  submitted  to  illustrate 
the  intimate  analogies  between  tics  and  obsessions. 

0.  is  a  great  cigarette  smoker,  and  with  him  the 
call  to  smoke  is  inexorable.  It  is  not  so  much,  how- 
ever, the  effects  of  the  narcotic  for  which  he  seeks 
a,s  the  sum  of  the  sensations  derived  from  the  act 
— the  rustling  of  the  tobacco  in  the  paper,  the  crackle 


14  TICS  AND    THEIR   TREATMENT 

of  the  match,  the  sight  of  the  cloud  of  smoke,  the 
fragrance  of  it,  the  tickling  of  nose  and  throat,  the 
touch  of  the  cigarette  in  the  fingers,  or  between  the  lips 
— in  a  word,  a  whole  series  of  stimuli,  visual,  auditory, 
olfactory,  and  tactile,  whose  habitual  repetition  gradually 
introduces  into  the  act  of  smoking  an  automatic  element 
that  brings  it  into  line  with  the  tics.  The  suppression 
of  this  parasitic  function  commonly  produces  a  feeling 
of  the  utmost  discomfort ;  inability  to  indulge  in  it 
causes  the  keenest  anguish.  More  agonising  than  the 
actual  impossibility  of  smoking  is  the  idea  of  its  being 
impossible.  Hence  it  is  that  0.  lights  cigarette  after 
cigarette,  taking  a  few  whiffs  at  each  and  throwing 
them  aside  scarce  touched,  or  leaving  them  here,  there, 
and  everywhere.  The  dose  is  immaterial ;  it  is  the 
rehearsal  of  the  act  he  finds  so  soothing. 

In  regard  to  his  taste  for  liquor  a  similar  description 
might  be  given.  The  intoxicating  effect  of  any  beverage 
had  little  attraction  for  him ;  it  was  the  drinker's 
gesture  and  the  numerous  accompanying  sensations 
that  he  sought  to  renew.  Any  form  of  drink,  therefore, 
served  to  gratify  his  desire ;  in  other  words,  his  behaviour 
revealed  a  phase  of  dipsomania  rather  than  a  stage  of 
alcoholism.  For  that  matter,  the  development  of 
symptoms  of  alcoholic  poisoning  proved  a  blessing 
in  disguise,  since  they  reinforced  the  inhibitory  power 
of  the  will,  and  enabled  it  to  abort  a  sensori-motor  habit 
that  had  wellnigh  become  established. 

No  objective  alteration  in  cutaneous  sensibility 
in  any  of  its  forms  is  discoverable  on  examination 
of  0.,  but  he  bewails  a  long  array  of  subjective 
sensations,  painful  or  disagreeable  as  the  case  may 
be.  Certain  abdominal  pains  in  particular  occupy  his 
thoughts :  after  being  in  bed  about  an  hour  he  begins 
to  suffer  from  pain  in  the  abdomen  and  across  the 
kidneys,  so  acute  that  he  is  forced  to  rise  and  walk 


THE  CONFESSIONS  OF  A    VICTIM  TO  TIC    i$ 

about  his  room,  or  sit  on  one  chair  after  another ;  at 
length  it  moderates  enough  to  allow  return  to  bed 
and  permit  of  sleep.  During  these  crises  there  is  no- 
sign  of  any  local  pathological  condition,  no  distention 
or  tenderness  or  evacuation  of  the  bowel.  They 
usually  last  for  some  days  at  a  time  and  disappear 
suddenly,  as  when,  after  several  nights'  and  days' 
uninterrupted  suffering,  his  pains  vanished  as  by  an- 
enchanter's  wand  once  he  set  foot  on  the  boat  that 
was  to  take  him  to  England. 

"We  have  had  the  opportunity  of  observing  our 
patient  in  the  throes  of  one  of  these  attacks,  and  while, 
we  did  not  doubt  the  genuineness  of  his  sufferings, 
we  could  not  but  be  struck  with  the  dramatic  exu-- 
berance  of  his  gestures.  He  wriggled  on  his  chair, 
unbuttoned  his  clothes,  undid  his  necktie  and  his 
collar,  pressed  his  abdomen  with  his  hands,  sobbed 
and  sighed  and  pretended  to  swoon  away.  Such  ex-. 
cessive  reaction  to  pain  is  characteristic  of  a  nervoua 
and  badly  trained  child,  not  of  a  man  of  his  years. 
Notwithstanding  his  humiliation  at  these  exhibitions, 
of  weakness,  he  can  no  more  control  them  than  he 
can  his  ordinary  tics ;  in  fact,  the  tics  run  riot  during- 
the  crises  of  pain. 

On  several  occasions  the  reflexes  have  been  the; 
object  of  examination.  The  pupillary  reactions  are 
normal,  as  are  the  tendon  reflexes  of  the  upper 
extremity ;  but  the  knee  jerks  are  much  diminished^ 
and  one  day  we  failed  to  elicit  them  at  all,  though 
we  noted  their  return  a  week  later.  A  careful  search 
for  further  signs  of  possible  cerebro-spinal  mischief 
proved  negative,  if  we  except  a  slight  flexion  of  the 
knees  when  walking  and  a  tendency  to  a  shuffling 
gait. 

Notwithstanding  this  absence,  in  O.'s  case,  of  any 
definite  indication  of  organic  disease,  we  cannot  afford,.. 


16  TICS  AND    THEIR   TREATMENT 

in  our  examination  of  patients,  to  overlook  any 
symptom,  however  fleeting  or  trivial  it  may  appear, 
since  it  is  only  by  painstaking  investigation  both  on 
the  physical  and  the  mental  side  that  we  can  ever 
hope  to  determine  the  characters  and  fathom  the 
nature  of  the  affection,  apart  from  the  value  of  such 
an  investigation  as  an  aid  to  diagnosis,  prognosis,  and 
treatment. 

With  charming  spontaneity  and  frankness,  but 
critically  withal,  0.  has  furnished  us  with  a  picture 
of  his  mental  state.  Nothing  could  be  truer  or  more 
instructive  than  this  piece  of  self-observation,  even 
though  his  obvious  pleasure  in  hearing  himself  talk 
is  a  little  weakness  of  which,  to  tell  the  truth,  he  is  the 
first  to  accuse  himself : 

In  childhood  and  at  school  my  accomplishments  were  ever  on  the  same 
dead  level  of  mediocrity.  I  was  neither  brilliant  nor  backward  ;  in  the 
drawing-room  or  in  the  playground,  I  was  good  at  everything  without 
excelling  in  anything  ;  the  astonishing  facility  with  which  I  learned  to 
sing,  play,  draw,  and  paint,  was  linked  with  inability  to  distinguish  myself 
at  these  pursuits. 

Each  new  study,  each  new  game,  attract  and  captivate  me  at  first, 
but  I  soon  tire  of  them,  and  once  a  fresh  enterprise  has  taken  their  place, 
indifference  to  them  changes  to  disgust.  If  I  am  amused  with  a  thing,  I 
do  it  well  ;  if  bored,  I  throw  it  aside.  I  suppose  it  is  characteristic  of 
people  who  tic  to  be  fickle  and  vacillating. 

The  versatility  which  is  so  fundamental  an  element 
in  O.'s  nature  has  not  been  prejudicial  to  his  business 
career.  He  has  managed  and  still  manages  important 
commercial  undertakings,  demanding  initiative  and 
decision,  and,  so  far  from  sparing  himself  in  any  way, 
he  has  exhibited  a  combination  of  caution  and  audacity 
that  has  stood  him  in  good  stead.  It  is  more  especially 
in  the  conduct  of  urgent  operations  that  his  alertness 
is  displayed.  His  comprehensive  grasp  of  the  situation 
enables  him  to  put  his  machinery  at  once  into  action, 


THE  CONFESSIONS  OF  A    VICTIM  TO  TIC     17 

with  eminently  satisfactory  results,  if  we  judge  by  his 
prosperous  and  assured  position. 

His  mobile  and  impulsive  temperament  is  revealed 
in  his  every  deed,  but  he  shows  at  the  same  time 
a  curious  disposition  to  alternate  between  the  pros 
and  the  cons  of  a  question.  It  is  the  outcome  of 
his  extremely  analytical  and  introspective  mind. 

I  find  myself  seeking  a  knot  in  every  bulrush.  I  experience  a 
sensation  of  pleasure  only  to  tax  my  ingenuity  in  discovering  some  danger 
or  blame  therein.  If  a  person  produces  an  agreeable  impression  on  me, 
I  cudgel  my  brains  in  the  attempt  to  detect  faults  in  him.  I  take  it 
into  my  head  to  ascertain  how  anything  from  which  I  derive  enjoyment 
might  become  an  aversion  instead.  The  absurdity  of  these  inconsistencies 
is  perfectly  patent  to  me,  and  my  reflections  occasion  me  pain  ;  but  the  , 
attainment  of  my  ends  is  accompanied  with  a  feeling  of  pleasure. 

In  regard  to  my  tics,  what  I  find  most  insupportable  is  the  thought 
that  I  am  making  myself  ridiculous  and  that  every  one  is  laughing  at 
me.     I  seem  to  notice  in  each  person  I  pass  in  the  street  a  curious  look 
of  scorn  or  of  pity  that  is  either  humiliating  or   irritating.     No  doubt 
my   statement   is   a   little   exaggerated,   but   my   fellows  and  I   have  an! 
overweening  self-conceit.     We  wish   to  be  ignored,  and  yet  we  wish  to 
be  considered  ;   it  is  annoying   to  be  the   object   of  sympathy,  but   we     , 
cannot  bear  to  become  a  laughing-stock.     Accordingly  our  goal  is   the 
dissimulation  of  our  failing  by  any  means  feasible  ;   yet  nine  times  out 
of  ten  our  efforts  are  abortive  simply  because  we  invent   a   tic    to  hide 

a  tic,  and  so  add  both  to  the  ridicule  and  the  disease. 

*• 

Alike  in  speaking  and  in  writing  0.  betrays  an 
advanced  degree  of  mental  instability.  His  conversation 
is  a  tissue  of  disconnected  thoughts  and  uncompleted 
sentences ;  he  interrupts  himself  to  diverge  at  a  tangent 
on  a  new  train  of  ideas — a  method  of  procedure  not 
without  its  charm,  as  it  frequently  results  in  picturesque 
and  amusing  associations.  No  sooner  has  he  expressed 
one  idea  in  words  than  another  rises  in  his  mind, 
a  third,  a  fourth,  each  of  which  must  be  suitably 
clothed ;  but  as  time  fails  for  this  purpose,  the  con-  J 
sequence  is  a  series  of  obscure  ellipses  which  are 
often  captivating  by  their  very  unexpectedness. 


{ 


1 8  TICS  AND    THEIR    TREATMENT 

His  writing  presents  an  analogous  characteristic. 

It  has  often  happened  that  I  have  commenced  a  business  letter  in 
the  usual  formal  way,  gradually  to  lose  sight  of  its  object  in  a  crowd  of 
superfluous  details.  Worse  still,  if  the  matter  in  hand  be  delicate  or 
wearisome,  my  impatience  is  not  slow  to  assert  itself  by  remarks  and 
reproaches  so  pointed  and  violent  that  my  only  course  on  reperusal  of 
the  letter  is  to  tear  it  up. 

By  way  of  precaution,  therefore,  0.  has  adopted 
the  plan  of  having  all  his  correspondence  re-read  by 
his  colleague.  Strangely  enough,  to  his  actual  cali- 
graphy  no  exception  can  be  taken.  The  firmness 
of  the  characters,  the  accuracy  of  the  punctuation 
and  accentuation,  the  straightness  of  the  lines,  are 
as  good  as  in  any  commercial  handwriting. 

With  the  aggravation  of  his  head  tics  writing 
has  become  a  serious  affair.  Every  conceivable  attitude 
has  been  essayed  in  turn,  and  at  present  the  device 
he  favours  is  to  sit  across  a  chair  and  rest  his  chin 
or  his  nose  on  the  back ;  in  this  fashion  he  can  write 
all  that  is  required. 

O.'s  every  act  is  characterised  by  extreme  im- 
patience. In  his  hurry  he  comes  into  collision  with 
surrounding  objects  or  breaks  what  he  is  carrying 
in  his  hand,  not  because  of  defective  vision  or  inco- 
ordination  of  movement,  but  because  of  his  eagerness 
to  be  done. 

In  spite  of  the  fact  that  I  know  my  recklessness  to  be  absurd,  that  T 
•ee  well  enough  the  obstacles  around  and  the  danger  of  an  encounter,  I  am 
conscious  of  a  paradoxical  impulse  to  do  exactly  what  I  should  not  do. 
In  the  same  instant  of  time  I  want  what  I  do  not  want.  As  I  pass 
through  a  door  I  knock  against  the  door-post  without  fail,  for  the  sole 
reason  that  I  would  avoid  it. 

There  is  impatience  in  his  speech.  His  volubility 
makes  him  cut  short  his  own  phrases  or  break  in 
upon  the  conversation  of  others.  If  an  idea  suggests 


THE  CONFESSIONS  OF  A    VICTIM  TO  TIC     19 

itself,  he  must  give  it  expression.  Perhaps  the  word 
wedded  to  the  idea  is  not  at  once  forthcoming,  yet 
he  does  not  hesitate  to  invent  a  neologism,  which 
is  often  amusing  in  spite  of  or  because  of  its  oddness, 
and  if  it  please  him  he  will  enter  it  in  his  vocabulary 
and  use  it  in  preference  to  the  other. 

To  wait  is  foreign  to  his  nature.  The  least  delay 
at  table  exasperates  him ;  any  order  he  gives  must 
be  executed  instanter ;  no  sooner  has  he  set  out  than 
he  would  be  at  his  journey's  end.  An  obstruction 
or  difficulty  in  the  way  is  the  signal  for  a  fresh 
outburst ;  his  irritation  soon  exceeds  all  bounds ;  his 
language  degenerates  into  brutality,  his  gestures  be- 
come increasingly  violent  and  menacing. 

It  is  not  with  any  surprise,  then,  that  we  learn 
in  O.'s  case  of  incipient  homicidal  and  suicidal  ideas. 

At  times  when  my  tics  were  in  full  force  evil  thoughts  have  often 
surged  over  me,  and  on  two  or  three  occasions  I  have  picked  up  a  revolver, 
but  reason  fortunately  has  come  to  the  rescue. 

As  a  matter  of  fact,  the  suicidal  tendencies  of 
some  sufferers  from  tic  are  seldom  full-blown.  The 
will  is  too  unstable  to  effect  their  realisation.  Hence 
the  patient's  hints  at  doing  away  with  himself  are 
nothing  more  than  empty  verbiage.  Similarly  with 
the  inclination  to  commit  homicide,  it  vanishes  as  soon 
as  it  arises. 

The  term  "  vertigos "  is  used  by  0.  to  designate 
a  long  series  of  little  "  manias "  or  obsessional  fears 
from  which  he  suffers,  among  which  may  be  enumerated 
dread  of  passing  along  certain  streets  and  a  consequent 
impulse  to  walk  through  others ;  dread  of  breaking 
any  fragile  object  he  holds  in  his  hands,  coupled 
with  the  temptation  to  let  it  fall;  fear  of  heights, 
and  at  the  same  time  a  desire  to  throw  himself  into 
space. 


20  TICS  AND   THEIR   TREATMENT 

I  have  often  stood  on  the  edge  of  the  pavement  waiting  for  a  vehicle 
to  pass,  and  at  the  moment  of  its  approach  darted  across  just  under 
the  horse's  nose.  On  each  occasion  I  have  been  conscious  equally  of  the 
absurdity  and  yet  of  the  irresistibility  of  the  idea  ;  each  time  the  attempt 
to  withstand  it  has  been  labour  lost. 

O.  is  a  great  nosophobe.  At  one  time  he  was 
immoderately  apprehensive  of  contracting  hydrophobia, 
and  used  to  flee  from  the  first  dog  he  saw.  To 
his  sincere  regret  he  had  several  of  his  pet  dogs 
killed,  because  of  his  conviction  that  they  would 
become  infected,  although  he  felt  such  harsh  measures 
to  be  quite  unjustifiable.  At  a  subsequent  stage  he 
turned  syphilophobe  for  no  adequate  reason.  He 
was  alarmed  lest  a  minute  pimple  on  his  chin  should 
develop  into  a  chancre.  Recently  his  chief  misgiving 
has  been  that  he  may  become  ataxic  or  demented. 

Among  his  various  afflictions  mention  must  be  made 
of  an  umbilical  hernia,  supposed  to  have  originated 
in  the  chafing  of  his  umbilicus  by  a  belt  he  was 
wearing  during  a  long  spell  in  a  canoe.  As  a  matter 
of  fact,  the  hernia  is  purely  imaginary — at  any  rate, 
there  is  no  trace  of  it  to-day.  Yet  at  the  first  it 
bulked  very  largely  in  his  mind,  and  he  is  still  fully 
persuaded  of  its  reality,  though  no  longer  of  its 
gravity. 

0.  further  complains  of  all  sorts  of  noises  in 
his  ears,  but  these  are  simply  the  ordinary  sounds  that 
one  can  produce  in  the  middle  ear  by  clenching  the  jaws 
together.  He  will  not  accept  so  obvious  an  explanation, 
however,  preferring  to  regard  them  as  indubitable 
evidence  of  the  "  lesion "  with  which  he  is  pre- 
occupied. The  tinnitus,  therefore,  is  rather  of  the 
nature  of  an  illusion  than  of  a  hallucination. 

He  is  distinctly  emotional,  and  lives  at  the  mercy 
of  his  emotions,  but  from  their  very  bitterness  he 
contrives  to  derive  some  pleasure.  His  passion  for 


THE  CONFESSIONS  OF  A   VICTIM  TO  TIC    21 

horse-racing  is  not  due  to  the  fascination  of  the  sport, 
but  to  a  bitter-sweet  sensation  which  the  excitement 
of  the  scene  calls  into  being.  He  is  indifferent  to 
arrest  or  aggravation  of  his  tics;  all  that  he  seeks  is 
the  association  of  a  certain  sense  of  anguish  with 
certain  "  tremolos  in  the  limbs,"  wherewith  he  is 
greatly  delighted. 

In  the  domain  of  his  affections  there  does  not 
appear  to  be  any  abnormality.  0.  is  an  excellent 
paterfamilias,  adoring  his  children,  but  spoiling  them 
badly  at  the  same  time.  In  this  part  of  our  examina- 
tion we  did  not  press  for  details,  but  as  far  as  we  have 
gathered  he  is  capable  of  sympathies  keenly  felt  though 
rarely  sustained. 

Thus,  whatever  be  the  circumstances,  changeableness, 
versatility,  want  of  balance,  are  manifested  clearly  in 
all  his  mental  operations ;  and  when  he  remarks  himself 
on  the  youthfulness  of  his  disposition,  he  is  simply 
stating  a  truism  as  far  as  those  who  tic  are  concerned, 
for,  in  spite  of  the  advance  of  years,  their  mental  con- 
dition is  one  of  infantilism. 

Under  our  direction  0.  has  devoted  several 
months  to  the  eradication  of  his  tics,  and  he  has  not 
been  slow  to  appreciate  the  aim  of  the  method  or 
to  acquire  its  technique.  One  of  the  first  results 
was  the  repudiation  of  various  procedures  more  harm- 
ful than  otherwise,  and  the  successful  endeavour  to 
maintain  absolute  immobility  for  an  increasing  space 
of  time.  The  outcome  of  it  all  has  been  a  gradual 
diminution  of  the  tics  in  number,  frequency,  and 
violence,  and  a  corresponding  physical  and  mental 
amelioration. 

We  do  not  intend  in  this  place  to  enlarge  on  the 
details  of  our  treatment:  suffice  it  to  say  that  it 
consisted  in  a  combination  of  Brissaud's  "movements 
of  immobilisation  "  and  "  immobilisation  of  movements  " 


22  TICS  AND    THEIR    TREATMENT 

with  Pitres's  respiratory  exercises  and  the  mirror 
drill  advocated  by  one  of  us.  To-day  the  utility 
of  these  measures  is  an  accepted  fact;  but  at  the 
same  time  we  rely  on  an  inseparable  adjunct  in 
the  shape  of  mental  therapeusis,  seeking  to  make 
the  patient  understand  the  rationale  of  the  discipline 
imposed. 

Our  task  has  been  lightened  to  an  unusual  degree 
through  O.'s  intimate  acquaintance  with  the  beginnings 
of  his  tics  and  his  striking  faculty  of  assimilation.  On 
many  occasions  he  has  anticipated  our  intentions  and 
of  his  own  accord  outlined  a  programme  in  harmony 
with  the  indications  we  were  about  to  give  him. 
Thanks  to  this  happy  combination  of  circumstances, 
the  improvement  effected  by  our  treatment  has  been 
quickly  manifested. 

I  am  conscious  of  very  material  gain.  I  do  not  tic  so  often  or  with 
such  force.  I  know  how  to  keep  still.  Above  all,  I  have  learned  the 
secret  of  inhibition.  Absurd  gestures  that  I  once  thought  irrepressible 
have  succumbed  to  the  power  of  application  ;  I  have  dispensed  with  my 
para-tic  cane  ;  the  callosities  on  my  chin  and  nose  have  vanished  ;  and 
I  can  walk  without  carrying  my  head  in  the  air.  This  advance  has  not 
been  made  without  a  struggle,  without  moments  of  discouragement  ; 
but  I  have  emerged  victorious,  strong  in  my  knowledge  of  the  resources  of 
my  will.  .  .  .  To  tell  the  truth,  at  my  age  I  can  scarcely  hope  for  an 
absolute  cure.  Were  I  only  fifteen,  such  would  be  my  ambition  ;  but 
as  I  am,  so  shall  I  remain.  I  very  much  doubt  whether  I  shall  ever  have 
the  necessary  perseverance  to  master  all  my  tics,  and  I  am  too  prone  to 
imagine  fresh  ones  ;  yet  the  thought  no  longer  alarms  me.  Experience 
has  shown  the  possibilities  of  control,  and  my  tici  have  lost  their  terror. 
Thus  have  disappeared  half  my  troubles. 

The  same  sagacity  that  0.  displayed  in  analysis 
of  his  tics  has  enabled  him  to  grasp  the  prin- 
ciples of  their  subjugation.  Notwithstanding  that  his 
guarded  prognosis  is  evidence  for  his  appreciation 
of  the  hindrance  his  peculiar  mental  constitution 
is  to  a  complete  cure,  he  has  impartially  put  on 


THE  CONFESSIONS  OF  A   VICTIM  TO  TIC    23 

record  his   definite    progress   towards   health   of   body 
and  mind. 

Such,  then,  is  the  faithfully  reported  story  of  our 
model,  such  are  his  confessions. 

During  ten  years'  intercourse  with  sufferers  from 
tic  it  has  been  our  interest  to  analyse  and  reconstruct 
the  pathogenic  mechanism  of  their  symptoms,  and 
in  the  vast  majority  of  cases  it  has  been  possible  to 
determine  the  origin  of  the  tics  and  to  confirm  the 
association  with  them  of  a  peculiar  mental  state. 
"We  have  thus  been  able  to  supplement  earlier  and 
weighty  contributions  to  the  subject  by  numerous 
suggestive  instances,  prominent  among  which  is  the 
case  of  0.,  whose  spontaneous  and  impartial  self-ex- 
amination forms  an  invaluable  clinical  document.  Its 
importance  is  enhanced  by  the  fact  that  its  observa- 
tions are  corroborated  by  a  survey  of  other  examples 
of  the  disease. 

With  commendable  good-humour,  keenness,  and 
sincerity,  0.  has  of  his  own  accord  plunged  into 
the  minutiae  of  his  malady,  and  exhibited  a  rare  appre- 
ciation and  precision  in  the  scrutiny  of  his  symptoms. 
The  mere  enumeration  of  them  stamps  the  record  as 
one  of  outstanding  clinical  importance,  but  it  is  the 
study  of  their  pathogeny  that  is  so  fascinating.  For 
a  moment  the  doubt  crossed  our  mind  that  O.'s 
explanations  might  be  merely  a  reflex  of  information 
culled  from  scientific  journals  or  of  conversations  with 
medical  friends,  but  this  is  not  so.  He  has  been 
prevented  by  his  profession  both  from  cultivating  a 
taste  for  and  from  devoting  any  leisure  to  psychological 
and  physiological  questions,  while  he  evinces  an  actual 
antipathy  to  medical  literature,  fearful  as  he  is  of 
contracting  disease.  The  point  we  are  desirous  of 
emphasising,  therefore,  is  simply  this :  that  the  results 


24  TICS  AND   THEIR   TREATMENT 

of  O.'s  voluntary  and  unprejudiced  self-examination 
are  in  perfect  harmony  with  the  declarations  of  our 
older  patients  and  with  the  statements  of  the  majority 
of  those  that  have  made  a  special  study  of  the  tics. 
For  these  reasons  we  have  taken  0.  as  the  prototype 
of  the  tiqueur. 


CHAPTEE  H 

HISTORICAL 

WE  have  just  become  acquainted  with  an  individual 
who  may,  we  believe,  be  considered  the  type 
of  a  species,  and  have  described  all  his  tics.     "What  is  a 
tic,  then  ? 

Its  etymology  has  not  much  information  to  furnish. 
The  probability  is  that  the  word  was  originally  onoma-  J 
topceic,  and  conveyed  the  idea  of  repetition,  as  in  tick- 
tack.  Zucken,  ziehen,  zugen,  tucken,  ticken,  tick,  in  the 
dialects  of  German,  tug,  tick,  in  English,  ticchio  in 
Italian,  tico  in  Spanish,  are  all  derivatives  of  the  same 
root.  It  matters  little,  in  fact,  since  the  term  is 
in  general  use  and  acceptable  for  its  shortness  and 
convenience.  In  popular  language  every  one  knows 
what  is  meant  by  a  tic  :  it  is  a  meaningless  movement 
of  face  or  limbs,  "  an  habitual  and  unpleasant  gesture," 
as  the  Encyclopedias  used  to  say.  But  the  definition 
lacks  precision. 

A  glance  at  the  history  of  the  word  will  reveal 
through  what  vicissitudes  it  has  passed.  "We  need  but 
remind  the  reader  of  its  exhaustive  treatment  in  the 
Dictionaries,  and  refer  him  for  an  elaborate  bibliography 
to  a  recent  work  by  R.  Cruchet,1  to  which  we  shall  have 
occasion  to  return. 

There   is   no    justification  for  regarding  the  risus 

1  RENE  CRUCHET,  "£tude  critique  sur  le  tic  convulsif  et  son 
traitement  gymnastique,"  These  de  Bordeaux,  1902. 

25 


26  TICS  AND    THEIR    TREATMENT 

sardonicus  of  the  ancients  as  a  tic.  All  that  we  can 
say  is  that  the  phrase  apparently  stood  for  a  complex 
of  facial  "  nervous  movements,"  whether  accompanied 
by  pains  and  paralyses  or  not.  Nor  can  the  rictus 
cani/nus  or  the  tortura  oris  have  been  other  than 
spasms  or  contractures  of  the  face. 

Previous  to  its  introduction  as  a  technical  term, 
the  word  tique,  ticq,  tic,  was  in  current  use  in  France, 
and  applied  in  the  first  place  to  animals.  In  1655  Jean 
Jourdin  described  the  tique  of  horses.  In  eighteenth- 
century  literature  tic  appears  in  the  sense  of  a 
"  recurring,  distasteful  act " — as  expressed  by  the 
Encyclopaedia — especially  in  individuals  revealing  cer- 
tain eccentricities  of  mind  or  character.  This  old-time 
opinion  is  worth  remembering,  particularly  in  view  of 
latter-day  theories. 

Once  adopted  by  the  eighteenth-century  physicians, 
the  application  of  the  word  was  extended  in  various 
directions.  Andre  (1756)  was  the  first  to  mention  tic 
douloureux  of  the  face,  an  affection  excluded  to-day 
by  common  consent  from  the  category  of  true  tics. 
Simple,  painless  convulsive  tic,  spreading  from  face 
to  arms,  and  to  the  body  as  a  whole,  was  differentiated 
by  Pujol  in  1785-7.  During  the  earlier  half  of  the 
nineteenth  century  no  solid  progress  was  achieved  by 
the  work  of  Graves,  Franpois  (of  Louvain),  Romberg, 
Niemeyer,  Valleix,  or  Axenfeld.  It  is  to  the  clinical 
genius  of  Trousseau  that  we  owe  the  rediscovery  of 
tic,  the  careful  observation  of  its  objective  manifesta- 
tions, and  the  recognition  of  accompanying  mental 
peculiarities. 

In  spite  of  the  fact  that  he  considered  it  a  sort 
of  incomplete  chorea,  and  classed  it  *  nosologically 
with  saltatory  and  rotatory  choreas  and  with  occupation 

1  TROUSSEAU,  Clinique  medicate  de  PHdtel  Dieu,  1873,  vol.  ii. 
p.  267  et  seq. 


HISTORICAL  27 

neuroses,  Trousseau's  original  account  remains  a  model 
of  clinical  accuracy  : 

Non-dolorous  tic  consists  of  abrupt  momentary  muscular  contrac- 
tions more  or  less  limited  as  a  general  rule,  involving  preferably  the 
face,  but  affecting  also  neck,  trunk,  and  limbs.  Their  exhibition  is 
a  matter  of  everyday  experience.  In  one  case  it  may  be  a  blinking 
of  the  eyelids,  a  spasmodic  twitch  of  cheek,  nose,  or  lip  $  in  another, 
it  is  a  toss  of  the  head,  a  sudden,  transient,  yet  ever-recurring  contortion 
of  the  neck  ;  in  a  third,  it  is  a  shrug  of  the  shoulder,  a  convulsive 
movement  of  diaphragm  or  abdominal  muscles, — in  fine,  the  term 
embodies  an  infinite  variety  of  bizarre  actions  that  defy  analysis. 

These  tics  are  not  infrequently  associated  with  a  highly  characteristic 
cry  or  ejaculation — a  sort  of  laryngeal  or  diaphragmatic  chorea — which 
may  of  itself  constitute  the  condition  ;  or  there  may  be  a  more  elaborate 
symptom  in  the  form  of  a  curious  impulse  to  repeat  the  same  word  or 
the  same  exclamation.  Sometimes  the  patient  is  driven  to  utter  aloud 
what  he  would  fain  conceal. 

The  advantage  of  this  description  is  its  applicability 
to  every  type  of  tic,  trifling  or  serious,  local  or  general, 
from  the  simplest  ocular  tic  to  the  disease  of  Gilles 
de  la  Tourette.  Polymorphism  is  one  of  the  tic's  dis- 
tinguishing features. 

Apart  from  his  studies  in  objective  localisation, 
Trousseau,  as  we  have  seen,  recognised  that  the  tic 
subject  was  mentally  abnormal,  but  the  credit  of  demon- 
strating the  pathogenic  significance  of  the  psychical 
factor  is  Charcot's.  Tic,  he  declared,1  was  physical  only 
in  appearance ;  under  another  aspect  it  was  a  mental 
disease,  a  sort  of  hereditary  aberration. 

Advance  along  the  lines  thus  laid  down  has  been 
the  work  more  especially  of  Magnan  and  his  pupils, 
of  Gilles  de  la  Tourette,  Letulle,  and  Guinon.  A 
meritorious  contribution  to  the  elucidation  of  the 
question  is  the  thesis  of  Julien  Noir,  written  under  the 
inspiration  of  Bourneville  and  published  in  1893.  The 
still  more  recent  labours  of  Brissaud,  Pitres,  and  Grasset 
1  CHARCOT,  Lefons  du  mardi,  1887-8,  p.  124. 


28  TICS  AND   THEIR   TREATMENT 

in  France,  and  of  others  elsewhere,  have  added 
materially  to  our  knowledge. 

Confining  ourselves  for  the  present  to  the  discussion 
of  the  latest  interpretations  put  on  the  word  tic,  we 
may  be  allowed  the  remark  that  if  the  influence  of 
Magnan's  teaching  has  been  instrumental  in  making 
our  idea  of  tic  conform  more  to  the  results  of  observa- 
tion, nevertheless  his  view  is  not  without  its  dangers. 

In  the  opinion  of  Magnan  and  his  pupils,  Saury 
and  Legrain l  in  particular,  the  tics  do  not  form  a 
morbid  entity ;  they  are  nought  else  than  episodic 
syndromes  of  what  Morel  called  "  hereditary  insanity," 
that  is  to  say,  of  what  is  usually  designated  nowadays 
"  mental  degeneration." 

Now,  if  by  degeneration  be  meant  a  more  or  less 
pronounced  hereditary  psychopathic  or  neuropathic 
tendency  which  betrays  itself  by  actual  physical  or 
psychical  stigmata,  then  tic  patients  are  unquestionably 
degenerates.  If  degeneration  unveils  itself  in  multi- 
farious psychical  or  physical  anomalies,  the  subjects 
of  the  tic  are  undoubtedly  degenerates.  If  a  degenerate 
may  suffer  from  one  or  other  variety  of  aboulia,  or 
phobia,  or  obsession,  the  man  with  tic  is  a  degenerate 
too. 

Thus  understood,  the  epithet  may  be  applied  to  all 
individuals  affected  with  tic.  In  fact,  they  must  be 
degenerates,  if  the  word  is  to  be  employed  in  its 
most  comprehensive  sense.  But  the  explanation  is 
insufficient,  inasmuch  as  the  converse  does  not  hold 
good;  all  degenerates  do  not  tic. 

We  may  be  safe  in  maintaining,  then,  that  tic 
is  only  one  of  the  manifold  expressions  of  mental 
degeneration,  but  we  are  not  much  enlightened  thereby. 
Obsessions  and  manias  similarly  are  indications  of  mental 
deterioration,  yet  the  fact  conveys  very  scanty  in- 

1  LEGRAIN,  "Du  deiire  des  d6g6n6r4s,"  These  de  Paris,  1885-6. 


HISTORICAL  29 

formation  as  to  their  real  nature.  Physical  anomalies — 
ectrodactyly,  for  instance — betoken  physical  degenera- 
tion, no  doubt;  but  are  inquiries  to  cease  with  this 
categorical  assertion  ?  Such  certainly  was  not  the  idea 
of  those  observers  whose  is  the  praise  for  having  de- 
monstrated the  common  parentage  of  the  heterogeneous 
manifestations  of  degeneration.  Synthesis  cannot 
exclude  the  work  of  analysis,  and  in  practice  there  is 
scarcely  a  case  to  which  this  doctrine  is  not  pertinent. 

Every  physical  and  every  mental  anomaly  is  the 
fruit  of  degeneration ;  every  individual  who  is  a  / 
departure  from  the  normal  is  a  degenerate,  superior  or 
inferior  as  the  case  may  be.  As  instances  of  the  latter 
we  may  specify  the  dwarf  and  the  weak-willed ;  of  the 
former,  the  giant  and  the  exuberant.  This  sane  and 
comprehensive  conception  of  the  subject  must  command 
universal  acceptance  as  a  synthetic  dogma,  but  it 
cannot  supplant  the  description  and  interpretation  of 
individual  facts.  However  legitimate  be  our  represen- 
tation of  tic  as  a  sign  of  degeneration,  it  is  obviously 
inadequate  if  we  rest  content  with  styling  its  subject 
a  degenerate. 

Unfortunately  the  inclination  too  often  is  to  be 
satisfied  with  the  term,  and  to  imagine  that  therewith 
discussion  terminates.  Still  more  unfortunately,  in 
concentrating  their  attention  on  the  mental  aspect  of 
the  disease,  some  have  altogether  lost  sight  of  one 
of  its  fundamental  elements,  viz.  the  motor  reaction, 
and  have  conceived  the  possibility  of  its  occurrence 
without  any  tic  at  all.  Cruchet  actually  postulates  i/ 
the  existence  of  an  exclusively  psychical  tic,  with  no 
external  manifestation. 

To  these  questions,  however,  we  shall  return.  The 
present  introductory  sketch  is  intended  merely  to 
demonstrate  the  ease  with  which  ambiguity  arises, 
and  the  desirability  of  its  removal.  We  are  fully 


30  TICS  AND    THEIR    TREATMENT 

conscious  of  the  value  of  the  work  of  Magnan  and 
his  school  in  emphasising  a  phase  of  the  subject  the 
exposition  of  which  can  only  result  in  gain. 

The  investigation  of  the  motor  phenomena  of  tic 
is  no  less  encircled  with  perplexities.  Not  only  are 
the  troubles  of  motility  boundless  in  their  diversity  and 
correspondingly  difficult  to  classify,  but  they  also  bear 
so  close  a  resemblance  to  a  whole  series  of  muscular 
affections  that  one  is  tempted  to  describe  a  special 
symptomatology  for  each  individual  case. 

For  several  years  there  has  been,  more  especially 
outside  of  France,  a  manifest  tendency  to  aggregate  all 
convulsions  of  ill-determined  type  into  one  great  class, 
under  the  name  "  myoclonus " ;  and  into  this  chaotic 
farrago,  it  is  to  be  feared,  will  tumble  a  crowd  of  con- 
ditions which  should  be  studiously  differentiated :  the 
tics,  electric  and  fibrillary  choreas,  paramyoclonus 
multiplex,  etc.,  etc. 

In  the  present  state  of  our  knowledge,  according 
to  Raymond,1  we  must  be  guided  by  the  lessons  of 
clinical  experience,  which  teach  us,  first,  that  the  vary- 
ing modalities  of  myoclonus  develop  from  the  parent 
stock  of  hereditary  or  acquired  degeneration ;  and, 
secondly,  that  transitional  forms  which  do  not  fall 
into  any  of  the  received  categories  are  of  common 
occurrence. 

From  a  general  point  of  view,  the  deductions  are 
entirely  reasonable.  There  is  a  suggestive  analogy 
between  these  conditions  and  the  muscular  dystrophies 
in  the  persistence  with  which  their  multiplicity  seems 
to  defy  the  efforts  of  classification.  The  analytic  stage 
witnessed  the  rapid  evolution  of  such  clinical  types  as 
the  facial,  the  facio-scapulo-humeral,  the  juvenile,  the 

1  RAYMOND,    Clinique  des  maladies  du  systeme  nerveux,   vol.    i. 
1896,  p.  551. 


HISTORICAL  31 

pseudo-hypertrophic,  not  to  mention  others  that  bear 
the  name  of  their  observer ;  but  it  has  been  succeeded 
by  the  synthetic  stage,  whose  function  it  is  to  incor- 
porate all  the  former  myopathies  in  the  comprehensive 
group  of  "  muscular  dystrophy." 

Yet  here,  again,  peril  lurks  in  too  hasty  a  general- 
isation. To  give  the  disease  a  name  is  not  equivalent 
to  pronouncing  a  diagnosis.  The  denominations 
"  myoclonus,"  "  muscular  dystrophy,"  "  degenerate," 
are  alike  inconvenient.  Their  scope  is  at  once  too 
inclusive  and  too  exclusive.  They  may  be  indispens- 
able ;  they  are  assuredly  not  sufficient. 

The  possibilities  of  misapprehension  do  not  end  here. 

The  manifestation  of  each  and  every  tic — be  it  a 
nicker  of  the  eyelid,  a  turn  of  the  head,  a  cry,  a  cough — 
is  through  the  medium  of  a  muscular  contraction.  On 
the  very  nature  of  this  contraction  opinion  is  divided. 

To  its  distinctive  features  of  abruptness  and  momen- 
tariness  is  due  the  epithet  "  convulsive "  habitually 
assigned  it,  but  the  qualification  is  not  secure.  Since 
the  time  of  Willis  the  word  convulsion  has  been 
employed  in  a  double  sense,  to  signify  clonic  muscular 
contractions  (the  "  convulsion "  of  popular  parlance) 
and  tonic  muscular  contractions  (a  meaning  attached 
to  the  term  only  by  the  scientist). 

For  our  part,  we  can  raise  no  valid  objection  to  the 
specification  of  tics  as  convulsive,  provided  always  that 
the  existence  of  clonic  convulsive  tics  and  of  tonic 
convulsive  tics  be  recognised.  As  a  matter  of  fact, 
clinical  observation  supplies  instances  of  both  sorts. 

Nevertheless,  attention  has  been  confined  by  a 
majority  of  authors  to  the  consideration  of  the  former 
variety  only,  so  much  so  that  a  whole  order  of  facts 
which  in  derivation,  essence,  and  external  characteristics 
ought  to  be  identified  with  the  tics  has  been  passed 
over  in  silence.  Even  on  the  assumption  that  the 


32  TICS  AND   THEIR   TREATMENT 

proposal  to  recognise  the  two  classes  cannot  be  enter- 
tained, at  the  least  it  is  advisable  to  predetermine 
the  import  of  the  word  convulsion,  and  to  speak 
of  clonic  convulsive  tics.  This  is  the  formula  of 
Ferrand  and  Widal  in  their  article  "  Convulsion "  in 
the  Encyclopaedic  Dictionary  of  the  Medical  Sciences. 
Similarly,  Troisier1  says  that  the  convulsive  tic 
properly  so  called  is  characterised  by  clonic  move- 
ments, in  which  opinion  Erb  and  most  German 
observers  concur.  Tonic  tic  appears  to  have  been 
forgotten,  and  we  have  thought  it  our  duty  to 
resuscitate  it. 

Cruchet  has  quite  recently  approached  the  subject 
in  a  critical  fashion : 

To  extend  the  term  tic  to  tonic  spasms  such  as  mental  torticollis, 
mental  trismus,  or  permanent  blepharospasm,  is  singularly  to  outstep  the 
limits  of  its  significance.  We  believe  Erb,  Troisier,  and  Oppenheim  are 
warranted  in  restricting  convulsive  tic  to  clonic  convulsions,  and  the  con- 
sequent simplification  and  elucidation  of  the  question  lead  us  to  adopt  the 
same  view. 

If  it  be  solely  a  matter  of  terminology,  and  if 
universal  consent  reserve  tic  for  convulsions  whose 
expression  is  clonic,  we  shall  be  the  first  to  withdraw 
the  phrase  "  tonic  tic,"  making  the  single  proviso  that 
some  other  designation  be  found  for  a  condition  which 
differs  from  the  clonic  tic  only  in  its  external  features, 
and  not  in  origin,  pathogeny,  or  treatment. 

What  is  this  other  name  to  be?  Are  these  tonic 
muscular  contractions  to  be  regarded  as  synonymous 
with  contractures  ?  If  so,  do  we  mean  myotetanic 
contracture — to  utilise  the  excellent  division  imagined 
by  Pitres — as  in  hysteria,  or  myotonic  contracture, 
as  in  Parkinson's  disease  ?  The  state  of  muscular 
contraction  in  tonic  tic  does  not  correspond  accur- 
1  TROISIER,  Dictionnaire  Dechambre,  art.  "  Face." 


HISTORICAL  33 

ately  to  either,  though,  it  is  certainly  more  akin  to  the 
myotonic  form;  but  myotonia  is  a  sort  of  caput 
mortuum  for  the  too  facile  classification  of  cases  in 
reality  difficult  to  place,  and  we  are  afraid  the  term 
is  not  calculated  to  ensure  precision  of  ideas. 

Should  we  be  reproached  with  straining  the  primary 
meaning  of  the  word  tic  by  applying  it  to  a  contraction 
of  a  certain  duration,  we  find  ample  justification  ready 
at  hand  in  the  pages  of  Cruchet  himself.  "It  was 
probably  in  1656,"  he  says,  "that  tique  appeared  in 
the  French  language,  in  the  works  of  Jean  Jourdin." 
Now,  in  the  quaint  description  of  the  horse's  tique 
given  by  that  writer,  the  signs  of  the  disease  are 
said  to  be  cocking  of  the  ears,  rolling  of  the  eyes, 
clenching  and  gnashing  of  the  jaws,  stiffening  of  the 
tail,  nibbling  at  the  bit,  etc.  What  else  are  these 
than  persistent  contractions  or  tonic  tics,  alternating 
or  co-existing  with  jerking  movements  or  clonic 
tics? 

"We  have  no  desire,  of  course,  to  over-estimate  the 
argumentative  value  of  this  passage,  the  interest  of 
which  is  mainly  historical ;  but  we  find  ourselves 
wholly  in  accord  with  Cruchet  when  he  remarks  of 
the  scientific  distinction  formulated  by  Willis,  and 
again  by  Michael  Etmiiller,  between  continuous, 
permanent  tonic  convulsions,  and  intermittent,  momen- 
tary clonic  convulsions,  that  it  is  uninvolved,  practical, 
and  of  universal  applicability. 

In  1768  certain  tics  were  classified  among  the  tonic 
convulsions  by  Boissier  de  Sauvages.  Marshal  Hall l 
gave  an  account  of  various  tonic  facial  convulsions 
to  which  Valleix  refers  as  non-dolorous  tics  or  idiopathic 
convulsions  of  the  face.  Coming  nearer  to  our  own 
times,  we  find  the  distinction  of  which  we  have  been 

1  HALL,  On  the  Disease  and  Derangement  of  the  Nervous  System, 
London,  1841. 

3 


34  TICS  AND    THEIR    TREATMENT 

speaking   again   elaborated  by  Jaccoud,1  in  1870,  and 
accepted  also  by  Eosenthal. 

Doubtless  physiologists  and  pathologists  are  not 
invariably  at  one  as  regards  the  proper  characters  of 
the  two,  and  subdivisions  into  continuous  tonic  con- 
tractions as  opposed  to  intermittent  tonic  contractions 
have  been  deemed  necessary;  but  without  burdening 
the  subject  with  a  plethora  of  detail,  we  think  it 
simple,  suggestive,  and  clinically  satisfactory  to  uphold 
"Willis's  generalisations  and  to  enlist  their  help  in  the 
exposition  of  the  tics.  Hence,  unless  under  special 
circumstances,  we  consider  recourse  to  the  epithet 
"  convulsive "  superfluous,  and  we  shall  employ  the 
word  tic  by  itself,  except  when  there  may  be  occasion 
to  indicate  the  form  of  muscular  contraction.  The 
gain  in  conciseness  is  not  likely  to  be  neutralised  by 
any  loss  of  precision. 

From  our  rapid  survey  of  the  vicissitudes  through 
which  the  tic  has  passed,  we  may  profitably  gather  one 
or  two  lessons. 

In  so  far  as  is  compatible  with  its  nature,  the 
schematisation  of  tic  is  indispensable.  The  inevitable 
variability  of  the  personal  factor  and  the  absence  of 
a  real  breach  of  continuity  between  any  two  essentially 
differing  morbid  affections  ought  not  to  deter  us  from 
the  attempt  to  project  a  line  of  demarcation  between 
them.  Natural  science  is  pledged  to  the  labour  of 
differentiation.  It  is  the  glory  of  Charcot's  alternately 
synthetic  and  analytic  work  to  have  demonstrated  the 
value  of  this  method  in  the  sphere  of  neuropathology. 
At  the  same  time,  the  wisdom  of  attaching  only  a 
provisional  importance  to  any  scheme  and  of  welcoming 
possible  modification  is  of  course  self-evident.  Inexact 
and  undiscriminating  inference  may  be  a  stumbling- 
block  in  the  path  of  progress  and  inimical  to  the 
1  JACCOUD,  Pathologie  interne,  t.  i.  1879,  pp.  595-8. 


HISTORICAL  35 

cultivation  of  the  faculty  of  observation.  Further, 
inaccuracy  of  definition  not  only  exaggerates  the  lia- 
bility to  misunderstanding,  but  has  sometimes  also 
the  disadvantage  of  promoting  an  illusory  belief  in 
the  possession  of  the  truth. 


CHAPTER   m 

THE   PATHOQBNY   OF   TIC 
TIC  AND  SPASM 

OUR  study  of  tic  can  be  approached  only  after 
a  preliminary  understanding  as  to  the  meaning 
of  two  words  too  frequently  confounded  even  in 
scientific  literature — tic  and  spasm.  Let  us  explain, 
then,  once  for  all,  exactly  what  we  intend  by  the  latter. 

Etymologically  (cnracr/io?,  oWta,  I  draw)  the  word 
signifies  a  twitch,  but  as  it  is  unfortunately  considered 
a  synonym  for  convulsion,  the  two  expressions  are 
used  indifferently  in  medical  parlance,  though  the 
desirability  of  restricting  the  application  of  the  former 
has  more  than  once  been  indicated.  Littre's  definition 
— "an  involuntary  contraction  of  muscles,  more 
particularly  of  those  not  under  voluntary  control " — 
may  appear  somewhat  idle,  as  the  contraction  of 
muscles  not  under  the  influence  of  the  will  can  scarcely 
be  other  than  involuntary.  His  intention  was,  no 
doubt,  to  reserve  spasm  for  convulsive  phenomena  in 
non-striped  muscle  fibres ;  but  in  this  limited  sense  the 
term  has  not  met  with  acceptance,  and  it  remains 
equivalent  to  "  involuntary  muscular  contraction," 
whatever  that  may  mean.  Thus  interpreted,  it  is 
applicable  to  any  and  every  involuntary  muscular 
movement,  physiological  and  pathological,  to  the  inco- 
ordination  of  tabes,  to  chorea,  athetosis,  tremor,  etc. 

Rather  than  imagine  a  new  substantive  to  cha- 

36 


THE  PAT  HOG  EN  V  OF  TIC  37 

racterise  certain  of  these  muscle  contractions,  we  may 
retain  the  word  in  a  somewhat  wider  though  equally 
precise  sense,  and  follow  the  distinction  drawn  by 
Brissaud l  in  1893 :  "  a  spasm  is  the  result  of  sudden 
transitory  irritation  of  any  point  in  a  reflex  arc  ;  .  .  . 
it  is  a  reflex  act  of  purely  spinal  or  bulbo-spinal  origin." 

By  definition,  then,  a  spasm  is  the  motor  reaction 
consequent  on  stimulation  of  some  point  in  a  reflex  spinal 
or  bulbo-spinal  arc.  To  differentiate  between  the 
reflex,  which  is  physiological,  and  the  spasm,  which  is 
pathological,  we  may  add  as  a  corollary :  the  irritation 
provocative  of  the  spasm  is  itself  of  pathological  origin, 
and  no  spasm  can  occur  without  it.  The  anatomo-patho- 
logical  substratum  of  a  spasm  is,  then,  some  focus  of 
irritation  on  a  spinal  or  bulbo-spinal  reflex  arc,  which 
may  be  situate  in  peripheral  end  organ,  in  centripetal 
path,  in  medullary  centre,  or  in  centrifugal  fibre. 
Whatever  be  its  localisation,  it  will  determine  a  spasm 
in  our  sense  of  the  word. 

Cortical  or  subcortical  excitation,  however,  as  well 
as  peripheral  stimuli,  may  provoke  these  bulbar  and 
spinal  centres  to  activity.  Irritation  of  a  point  on 
the  rolandic  cortex,  or  on  the  cortico-spinal  centripetal 
paths,  is  followed  by  a  motor  reaction  exactly  as  with 
afferent  impulses ;  the  sole  change  is  in  the  route  taken 
by  the  centripetal  stimulus ;  the  reflex  centre  remains 
bulbo-spinal,  and  the  efferent  limb  of  the  arc  is  as 
before. 

The  application  of  the  word  spasm  to  these  motor 
responses  to  cortical  or  subcortical  stimulation  is  quite 
justifiable.  Developmentally  the  grey  matter  of  the 
cerebral  convolutions  is  ectodermic,  as  is  the  skin,  and 
capable  of  functioning  as  a  sensory  surface ;  it  may 
be  considered  the  end  organ  of  an  afferent  path  that 

1  BRISSAUD,  Lemons  sur  les  maladies  netveuses,  ist  series, 
chap.  xxiv.  p.  506. 


38  TICS  AND    THEIR    TREATMENT 

conducts  to  medullary  reflex  centres.  According  to 
our  definition,  then,  provided  the  centre  of  the  reflex 
arc  be  bulbo-spinal  and  the  irritation  pathological, 
the  consequent  motor  phenomenon  is  a  spasm. 

A  distinction  must  nevertheless  be  drawn  between 
the  two  cases,  inasmuch  as  in  the  one  the  afferent  path 
is  peripheral,  in  the  other  it  is  cortico- spinal,  and  there 
is  a  corresponding  difference  in  the  clinical  picture. 
Jacksonian  convulsions,  consecutive  to  cortical  stimula- 
tion, do  not  seem  to  bear  much  resemblance  to  spas- 
modic movements  indicative  of  peripheral — i.e.  sensory 
nerve — irritation.  As  a  matter  of  fact,  it  is  not  always 
easy  to  differentiate  the  two,  except  by  the  aid  of 
concomitant  phenomena.  The  characteristic  evolution 
of  the  Jacksonian  convulsion  is  of  course  readily 
recognisable.  We  can  similarly  diagnose  an  irritative 
lesion  of  the  internal  capsule  not  so  much  from  the 
objective  features  of  the  convulsive  movements  as  from 
accompanying  indications.  In  short,  there  need  never 
be  any  occasion  for  confusion.  Convulsive  conditions 
attributable  to  irritation  of  cortico-spinal  centripetal 
paths  have  long  been  described  and  analysed:  they 
constitute  well-recognised  morbid  entities,  among  which 
may  be  enumerated  Jacksonian  epilepsy,  hemichorea, 
hemiathetosis,  pre-  and  post-hemiplegic  hemitremor, 
etc. 

These  clinical  denominations  for  the  affections  under 
consideration  it  is  at  present  desirable  to  retain.  We 
shall  not  call  them  spasms  ;  above  all,  we  must  not  call 
them  tics,  else  we  shall  end  by  confounding  conditions 
absolutely  distinct.  The  case  recorded  by  Lewin,1 
under  the  title  of  "convulsive  tic,"  of  a  three-year- 
old  infant  still  unable  to  walk,  who  has  daily  attacks 
in  which  "  all  the  muscles "  twitch  for  about  a  minute 
at  a  time,  is  indeed  a  most  singular  tic.  We  were 
1  LEWIN,  Arch,  d.phys.  diat.  Therapie,  1900,  p.  281. 


THE   PATHOGENY  OF   TIC  39 

under  the  impression  that  such  an  attack  is  usually 
known  as  an  epileptiform  convulsion.  Is  the  term 
"  convulsive  tic  "  quite  a  happy  synonym  ? 

Again,  in  the  recent  thesis  of  Cruchet  the  attempt 
has  been  made  to  base  the  pathological  physiology  of 
tic  on  researches  of  von  Monakow  and  Muratow  apropos 
of  the  occurrence  of  choreic,  epileptoid,  or  athetotic 
movements  after  certain  lesions  of  the  cerebro-spinal 
axis,  and  to  find  an  analogy  in  the  action  of  various 
convulsion-producing  substances  (E-ichet  and  Langlois). 
Cruchet' s  conclusion  is  that  convulsive  tic  is  as  often 
cortical  or  subcortical  as  spinal  in  origin ;  that  it  is, 
in  short,  a  mere  symptom,  common  to  many  cerebro- 
spinal  conditions. 

The  same  regrettable  confusion  is  discernible  in 
various  treatises  on  neuropathology  the  work  of  German 
and  other  foreign  authors. 

As  far  as  we  are  concerned,  the  outcome  of  the  whole 
matter  is  simply  this:  if  tic  is  doomed  to  be  used 
indifferently  for  convulsion,  its  retention  in  scientific 
terminology  is  unjustifiable.  Rather,  then,  than  widen 
its  application,  we  prefer  to  restrict  it ;  we  shall  employ 
the  term  convulsion  in  its  most  general  sense  of  "  any 
anomaly  due  to  excess  of  muscular  contraction,"  of 
whatever  variety  or  origin ;  and  we  shall  limit  the  use 
of  the  word  spasm  to  phenomena  the  result  of  irritation 
at  any  point  on  afferent  or  efferent  reflex  paths,  or  in 
reflex  bulbo-spinal  centres. 

In  thus  indicating  our  position,  we  find  ourselves 
once  more  in  accord  with  generally  received  opinion 
since  the  days  of  Charcot.  These  views  have  been 
excellently  expressed  by  Q-uinon : 

Convulsive  movements  differ  widely  in  kind.  Some  consist  of  localised 
spasms  in  the  domain  of  a  motor  or  mixed  nerve,  most  frequently  one  of 
the  cranial  series — in  especial  the  seventh — consecutive  to  some  anatomical 
lesion,  central  or  peripheral.  The  great  majority  of  observers,  French  and 


40  TICS  AND   THEIR   TREATMENT 

foreign  alike,  are  in  the  habit  of  designating  such  movements  "tic»."  .  .  . 
But  they  are  only  partial  convulsions  limited  to  the  area  of  some  one 
nerve,  not  true  convulsive  tics,  differing  alike  in  essential  features  and 
concomitant  symptoms.  From  the  anatomo-pathological  standpoint,  more- 
over, lesions  are  as  constantly  present  in  the  one  as  absent  in  the  other. 

The  opinion  of  Brissaud  on  the  subject  coincides 
with  our  own. 

If  we  suppose  now  that  the  cortex  ceases  to  act 
as  a  surface  of  peripheral  excitation,  and  becomes 
itself  a  reflex  centre,  we  note  at  once  a  complete 
change.  The  modification  effected  by  the  cortex 
on  afferent  impressions  is  obvious  in  altered  motor 
reactions,  which  appear  with  the  stamp  of  cortical  inter- 
vention, herein  differing  from  bulbo-spinal  phenomena. 
To  this  category  belong  the  tics ;  we  shall  soon  see  why 
and  how. 

Conformably,  then,  to  convention  sanctioned  by 
usage,  and  especially  by  the  teaching  of  Charcot  and 
Brissaud,  we  have  given  a  precise  definition  to  the  word 
spasm,  and  we  can  only  solicit  its  general  adoption. 

To  resume  briefly  the  argument  we  have  advanced 
in  the  foregoing  paragraphs,  we  maintain: 

If  in  a  given  motor  phenomenon  there  is  no  evidence 
of  actual  or  previous  cortical  intervention,  it  is  not  a  tic. 

If  the  motor  reaction  is  consecutive  to  pathological 
irritation  at  any  point  on  a  bulbo-spinal  reflex  arc,  it 
is  a  spasm. 

If  the  cortex  is  or  has  been  involved  in  its  production, 
it  is  not  a  spasm. 

Should  it  present,  in  addition  to  the  fact  of  cortical 
participation,  certain  distinctive  pathological  features, 
it  is  a  tic. 

It  is  precisely  these  distinguishing  characteristics  that 
we  shall  now  proceed  to  examine,  preluding  our  study  of 
them  with  one  or  two  physiological  considerations. 


THE   PATHOGENY  OF  TIC  41 

TIC  AND  MOTOR  REACTIONS;   REFLEX,  CO-ORDINATED, 
FUNCTIONAL,   AUTOMATIC,   AND  VOLUNTARY  ACTS 

The  instantaneous  muscular  contraction  that  follows 
the  application  of  a  drop  of  sulphuric  acid  to  the  limb 
of  a  decerebrate  frog  is  an  example  of  a  pure  spinal 
reflex.  "With  the  persistence  of  the  irritation  contrac- 
tion of  the  other  limb  and  of  the  whole  body  ensues ; 
the  simple  spinal  reflex  has  become  generalised.  Observe 
the  frog  a  little  longer.  Soon  the  sound  foot  approaches 
the  affected  limb  and  attempts  by  rubbing  to  remove 
the  point  of  irritation.  A  movement  of  attack  has 
succeeded  the  simple  movement  of  defence,  and  indicates 
a  complete  change  in  the  nature  of  the  motor  reaction. 
In  the  first  case  the  limb  is  withdrawn  briskly  from  the 
painful  stimulus ;  in  the  second  the  animal  performs  a 
series  of  co-ordinated  purposive  movements.  The  first 
reflex  is  automatic,  and  so  no  doubt  is  the  second,  since 
the  frog  is  decerebrate.  But  a  co-ordinated  movement 
is  not  of  necessity  automatic  from  the  outset ;  its  auto- 
matism may  be  the  sequel  to  voluntary  education.  Co- 
ordination is  often  a  manifestation  of  cortical  activity. 

Take,  next,  the  case  of  the  infant.  His  earliest 
muscular  movements  are  pure  spinal  reflexes.  Pinch 
his  leg,  and  he  withdraws  it ;  continue  the  stimulus,  and 
he  moves  the  other  leg,  his  arms,  his  whole  body ;  he 
starts  to  cry.  The  original  reflex  is  becoming  general- 
ised, yet  he  makes  no  attempt  to  remove  the  source 
of  irritation.  Should  a  particle  get  into  his  eye,  his 
lids  will  blink  so  long  as  the  pain  persists,  but  he  never 
rubs  them  to  expel  the  foreign  body.  In  Virchow's 
phrase,  the  newborn  infant  is  a  spinal  animal,  endowed 
with  spinal  reflexes  only;  his  responses  to  stimuli  are 
beyond  voluntary  control. 

More  complex  motor  phenomena,  however,  equally 
independent  of  cortical  influence,  characterise  the  early 


42  TICS  AND    THEIR   TREATMENT 

days  of  the  infant's  life.  The  contact  of  his  lips  with 
the  breast  at  once  elicits  a  reflex  in  the  shape  of  suck- 
ing movements.  These  are  obviously  co-ordinated  and 
•adapted  for  a  particular  end;  suction  is  a  functional 
act.  Yet  the  cortex  plays  no  part  therein ;  the  act  is 
automatic  from  the  beginning.  Peripheral  excitation 
from  tactile  impression  of  nipple,  teat,  or  finger  is 
sufficient  to  provoke  this  reflex  response. 

Similarly  with  the  functions  of  respiration  and 
nictitation — their  establishment  follows  the  stimulation 
by  air  of  the  respiratory  or  conjunctival  mucosa.  The 
appropriate  movements  constitute  the  spontaneous  re- 
action to  afferent  impulses;  they  are  simple  bulbar 
reflexes.  Co-ordinated  and  purposive  though  they  be, 
they  do  not  come  within  the  sphere  of  the  will.  The 
newborn  child  cannot  voluntarily  accelerate  or  retard 
his  respiratory  rhythm. 

But  a  day  comes  when  the  formation  of  cortico- 
bulbar  or  cortico-spinal  anastomoses  renders  possible 
the  interaction  of  higher  and  lower  centres ;  respira- 
tion may  be  made  quicker  or  slower;  the  eyelid  may 
be  closed  less  rapidly,  more  often.  In  a  word,  cortical 
modification  of  function  becomes  a  reality. 

A  further  step  in  advance  is  soon  taken. 

Under  the  "  law  of  least  effort "  the  inhibitory  power 
of  the  will  reduces  motor  reaction  for  the  attainment 
of  a  given  object  to  a  minimum.  The  infant  begins 
to  make  more  complicated  movements,  attempting  the 
removal  of  a  source  of  annoyance  by  direct  attack, 
learning  to  scratch  itself,  to  spit  instead  of  swallow,  etc. 

The  essential  difference  between  these  acts — a 
thousand  other  examples  might  be  chosen — and  the 
reflexes  of  the  first  group,  is  that  the  precise  and 
regular  execution  of  the  former  demands  more  or  less 
prolonged  education,  repetition,  and  voluntary  co- 
ordination. 


THE  PATHOGENY  OF   TIC  43 

It  is  true  these  co-ordinated  acts  are  eventually 
performed  with  all  the  spontaneity  of  the  simplest 
reflexes ;  voluntary  co-operation  is  no  longer  indis- 
pensable ;  scratching,  spitting,  walking,  can  be  effected 
without  any  actual  intervention  of  the  will.  But  we 
must  not  forget  such  muscular  automatism  entails  a 
preliminary  training  in  the  shape  of  frequent  repetition 
of  purposive  movements — a  training  which  varies  in 
duration  with  the  individual  and  the  nature  of  the 
particular  movement.  It  is  only  after  several  years  of 
volitional  effort  that  such  acts  as  locomotion  or  the 
expulsion  from  the  throat  of  an  irritant  particle  be- 
come really  automatic. 

The  fact  that  the  newly  hatched  chick  is  capable 
of  walking  has  been  advanced  as  an  argument  for  the 
existence  of  congenital  automatism.  It  is  true  that  the 
chick's  movements  are  very  imperfect — it  stumbles  and 
falls,  as  does  the  infant,  on  the  slightest  provocation, 
and  even  without  any  apparent  cause  ;  but  the  rapidity 
with  which  certain  animals  acquire  the  faculty  is  so 
surprising  that  the  latter  almost  appears  to  have  been 
innate. 

In  all  phenomena  characterised  as  instinctive  we 
cannot  deny  the  existence  of  a  certain  congenital 
aptitude,  the  result  possibly  of  ancestral  education, 
owing  to  which  some  individuals  learn  infinitely  more 
quickly  than  others,  and  in  their  case  a  period  of 
preliminary  education  may  seemingly  be  awanting. 
Probably  the  truth  is,  however,  that  this  stage  has  been 
a  very  brief  one.  In  man  there  is  a  gradual  trans- 
formation of  voluntary  into  automatic  acts.  Though  no 
teacher  be  necessary,  teaching  is  requisite.  The  infant 
learning  to  walk  is  really  independent  of  his  parents, 
and  might,  for  that  matter,  be  entirely  self-taught ; 
but  the  point  remains,  however  automatic  his  walking 
subsequently  become,  that  he  begins  by  voluntarily 


44  TICS  AND   THEIR   TREATMENT 

co-ordinating  the  movements  of  his  lower  limbs  and 
trunk  towards  a  definite  end. 

Another  advance  is  still  to  be  made. 

With  increasing  cortical  development  the  individual 
is  able,  on  stimulation  no  longer  peripheral  but  central 
in  origin,  spontaneously  to  execute  movements  which 
frequent  repetition  has  endowed  with  all  the  features  of 
functional  acts.  Of  these  ideomotor  phenomena  physical 
exercises,  games,  manual  trades,  readily  furnish  instances. 
Swimming,  for  an  instance,  requires  the  rhythmical  co- 
ordination of  arm  and  leg,  to  attain  which  perseverance, 
retentiveness,  and  above  all  repetition  are  essential. 
At  length  the  time  arrives  when  the  swimmer  is 
surprised  at  the  absence  of  any  necessity  for  voluntary 
co-ordinating  effort  on  his  part.  In  fact,  to  reintroduce 
volition  into  this  acquired  automatism  would  be  to 
court  disaster.  "  "What  I  do  naturally,"  said  Montaigne, 
"  I  can  no  longer  perform  if  I  attempt  it  expressly." 

From  these  physiological  considerations  we  are  led 
to  make  the  following  classification  of  motor  reactions : 

1.  Simple  spinal  reflexes,  innocent  of  co-ordination 

or  functional  systematisation,  on  whose  pro- 
duction or  inhibition  the  will  has  no  influence. 
To  this  division  belong  the  movements  known 
as  spasms. 

2.  Functional  motor  acts.     Among  these  we  may 

distinguish : 
a.  Essential  movements,  e.g.  respiration,  suction, 

etc.,  appearing  at  birth,  and  co-ordinated  in 

view  of  some  definite  function. 
6.  Acts    such    as    locomotion,    mastication,    etc., 

whose  acquisition  is  subsequent  to  a  more  or 

less  prolonged  period  of  education. 
c.  Non-essential  ideomotor  acts,  acquired  later  in 

life,  which  soon  assume  all  the  characters  of 

functional  acts. 


THE  PATHOGENY  OF   TIC  45 

The  movements  belonging  to  the  first  group  in  this 
latter  category  may  manifest  themselves  without  any 
exertion  on  the  part  of  the  will,  but  its  activity  is 
essential  to  the  perfecting  of  the  second,  and  the 
originating  of  the  third. 

In  this  last  division  are  placed  the  motor  phenomena 
known  as  tics. 


TIC    AND    CO-ORDINATION 

We  have  thus  come  to  see  that  a  tic  is  a  co- 
ordinated, systematised,  purposive  act.  The  majority 
of  observers  are  satisfied  on  this  point,  although  there 
exist  various  differences  of  opinion,  more  apparent  than 
real,  the  inevitable  result  of  disagreement  as  to  the 
interpretation  of  certain  expressions.  It  is  imperative 
to  obviate  misunderstanding  once  and  for  all. 

In  his  first  contribution  to  the  study  of  the  disease 
which  bears  his  name,  Gilles  de  la  Tourette  gave  the 
general  description  of  motor  inco-ordination  to  the  con- 
vulsive movements  of  his  patients.  It  has  been  argued 
by  Guinon,  on  the  contrary,  that  they  are  really 
systematised,  and  that  they  reproduce,  in  an  involuntary 
manner,  the  co-ordinated  movements  of  everyday  life. 
That  this  is  sometimes  the  case  Tourette  subsequently 
admitted,  but  he  still  professed  their  frequent  actual 
inco-ordination. 

This  divergence  of  opinion  is  entirely  attributable 
to  difference  of  interpretation.  Littre's  definition  of 
muscular  inco-ordination  is,  "  A  condition  occurring  in 
various  diseases  of  the  nervous  system,  in  which  the 
patient  cannot  co-ordinate  the  necessary  muscular 
movements  for  walking,  grasping  an  object,  etc."  In 
this  sense  the  term  is  applicable  indiscriminately  to 
the  gesticulations  of  choreic,  athetotic,  or  tic  patients ; 
to  the  ataxia  of  tabetics  and  others ;  to  the  tremor  of 


46  TICS  AND   THEIR    TREATMENT 

disseminated  sclerosis  or  paralysis  agitans,  etc.  An 
expression  so  general  is  not  merely  of  no  diagnostic- 
value  ;  it  leads  to  positive  confusion. 

It  is  precisely  in  the  type  of  inco-ordination  that 
the  difference  lies.  As  rigorous  a  distinction  must 
be  drawn  between  the  gestures  of  chorea  and  the 
gesticulations  of  the  sufferer  from  tic  as  between  the- 
tremor  of  insular  sclerosis  and  of  Parkinson's  disease. 

In  assigning  an  exact  meaning  to  the  term  muscular 
inco-ordination,  we  cannot  do  better  than  quote  the 
remarks  of  Guinon  : 

The  tabetic  who  throws  his  legs  to  right  and  left,  who  as  he  sits  at 
table  cannot  carry  his  spoon  to  his  mouth,  furnishes  an  instance  of  true 
motor  inco-ordination.  On  the  other  hand,  the  subject  of  tic  performs, 
his  voluntary  actions  with  perfect  assurance  ;  though  his  infirmity  occasion 
all  sorts  of  ridiculous  involuntary  arm  movements,  he  never  brings  his; 
fork  against  his  ear  or  his  cheek,  nor  does  he  spill  a  drop  from  his  glass  j 
his  walk  may  be  interrupted  by  a  sudden  halt  to  bend  his  knees  and  kneel, 
or  to  strike  his  foot  violently  on  the  ground,  but  he  never  trips  one  leg 
over  the  other  and  never  falls. 

In  his  article  in  the  Dictionnaire  Jaccoud,  Letulle> 
distinguishes  two  kinds  of  tics  : 

The  con"»ulsffe  fie  consists  of  a  series  of  partial  convulsions,  while  the  co- 
ordinated tic  is  the  expression  of  some  complex  act  by  a  sequence  of  muscular 
contractions  for  that  purpose.  In  the  former  case  the  resulting  movement 
is  irregular,  abnormal,  and  useless  ;  it  is  a  muscular  "  shock "  evolved 
without  reason  and  continued  without  effect.  .  .  .  The  normal  individual 
usually  possesses  in  fotentia  all  the  elements  for  the  genesis  of  a  co-ordinated 
tic.  Some  little  trick  or  mannerism,  arising  perhaps  from  the  necessity 
of  gaining  time  for  reflection,  or  from  the  desire  of  concealing  some- 
innate  timidity,  or  of  dissimulating  some  preoccupation,  becomes  soonen- 
or  later  involuntary  and  automatic,  and  though  maintaining  its  regularity 
and  co-ordination,  passes  insensibly  into  the  realm  of  pathology. 

The  distinction,  however,  is  far  from  being  absolute. 
Letulle  himself  admits  it  is  a  question  of  degree  rather 
than  of  kind ;  the  co-ordinated  tic  differs  from  the  first 
variety  only  in  its  greater  extent,  complexity,  and 


THE  PATHOGENY  OF  TIC  47- 

duration.  Now,  the  convulsive  tic  may  be  a  local,  partial,, 
irregular,  abnormal  convulsion,  yet  these  characteristics 
are  not  sufficient  to  differentiate  it:  biting  the  lips  is 
classed  by  Letulle  as  a  co-ordinated  tic,  but  it  is  surely  a 
local,  partial,  irregular,  abnormal  muscular  act ;  and  the 
explosive  laryngeal  "  ahem  !  "  he  would  similarly  place, 
yet  it  cannot  be  said  to  be  a  phenomenon  characterised 
by  its  extent,  complexity,  and  duration. 

According  to  Guinon,  a  further  distinguishing 
feature  of  the  convulsive  tic  is  its  frequent  though 
inopportune  reproduction  of  some  reflex  or  automatic 
purposive  movement  of  everyday  life,  whereas  we  have 
just  seen  that  one  of  the  elements  in  Letulle's  co- 
ordinated tic  is  its  purposiveness.  In  a  word,  these  ob- 
servers apply  the  same  epithet  to  two  varieties  of  tic 
which  they  are  endeavouring  to  separate. 

The  explanation  of  the  apparent  contradiction  is 
simple.  A  gesture  which  seems  meaningless  and  useless- 
to-day  becomes  intelligible  and  logical  to-morrow, 
when  we  learn  the  reason  for  it.  In  the  course 
of  an  attack  of  conjunctivitis  a  patient  acquires  the- 
habit  of  winking  his  eye,  and  though  the  inflammation 
subsides,  the  habit  persists.  If  we  are  ignorant  of  it» 
cause,  are  we  to  call  the  tic  convulsive  since  it  appears 
to  us  needless  ?  And  if  we  do  know  its  origin,  can- 
we  say  it  is  co-ordinated  when  one  muscle  only  is: 
involved  in  the  contraction  ? 

The  distinction  drawn  by  Letulle  between  the  two- 
groups  may  hold  good  in  some  cases,  but  certainly  not 
in  all,  and  in  our  opinion  it  is  preferable  to  abstain 
entirely  from  the  attempt  to  base  a  classification 
on  variation  in  muscular  contraction.  Noir  remarks 
very  justly  that  intermediate  forms  occur  which  are 
difficult  to  place  in  one  or  other  category.  In  face 
of  the  confusion  to  which  an  illogical  division  in- 
evitably leads,  we  may  safely  leave  this  question. 


48  TICS  AND   THEIR   TREATMENT 

aside.  In  our  view,  the  motor  phenomena  of  the 
disease  are  always  systematic,  co-ordinated  movements, 
directed  for  the  attainment  of  some  definite  object.  We 
exclude  all  simple  bulbar  or  spinal  reflexes,  and  all 
spasms,  since  the  cardinal  feature  in  these  conditions 
is  the  absence  of  any  functional  systematisation. 

THE  GENESIS  OF  TIC 

We  have  seen  how  various  purposive,  co-ordinated 
movements  may,  by  dint  of  education  and  voluntary  repe- 
tition, become  automatic  and  be  automatically  repeated 
should  occasion  arise.  Imagine  some  such  act  recurring 
involuntarily  without  any  apparent  reason  and  for  no 
apparent  object ;  what  does  such  an  anomaly  signify  ? 

Take,  for  instance,  the  case  of  a  young  girl  who 
inclines  her  head  on  her  shoulder  to  relieve  the  pain 
of  a  dental  abscess.  The  act  is  called  forth  by  a  real 
exciting  cause;  the  muscular  response  is  voluntary, 
deliberate,  undeniably  cortical  in  origin :  the  patient 
wills  to  appease  the  pain  by  pressing  and  warming 
her  cheek.  Should  the  abscess  persist,  the  movement 
will  be  repeated  less  and  less  voluntarily,  more  and 
more  automatically ;  but  as  the  why  and  the  wherefore 
still  remain,  there  is  nothing  pathological  about  it. 

With  the  healing  of  the  abscess,  however,  and  the 
consequent  relief  of  the  pain,  the  girl  still  inclines  her 
head  on  her  shoulder  from  time  to  time,  albeit  cause 
and  purpose  have  ceased  to  operate.  Her  primarily 
volitional,  co-ordinate,  systematic,  motor  reaction  is  now 
automatic,  inopportune,  and  meaningless  :  it  is  a  tic. 

Charcot1  has  given  us  an  excellent  description  of 
the  process: 

However  complex  and  bizarre  may  appear  the  convulsive  phenomena 
known  as  tics,  they  are  not  always  as  irregular,  inco-ordinate,  and  con- 
1  CHARCOT,  Lemons  du  mardi,  1889,  p.  464, 


THE  PATHOGENY  OF   TIC  49 

tradictory  as  superficial  examination  might  lead  one  to  believe.  On  the 
contrary,  they  are,  as  a  general  rule,  systematised  ;  in  a  given  case  they 
recur  always  in  an  identical  manner,  reproducing,  and  simultaneously 
exaggerating,  complex,  automatic,  purposive  movements  which  are  es- 
sentially physiological  ;  they  are  in  a  sense  the  caricatures  of  ordinary 
acts  and  gestures.  The  tic  is  not  in  itself  absurd  ;  it  appears  so  only 
because  it  occurs  inappositely,  without  obvious  motive.  Source  of 
irritation  is  absent,  yet  the  patient  scratches  himself ;  he  blinks,  but  no 
foreign  body  is  to  be  detected  in  his  eye. 

Mere  repetition  does  not,  cannot,  evolve  a  tic  in 
every  case.  Not  all  who  would  may  tic ;  psychical 
predisposition  in  the  shape  of  volitional  enfeeblement 
is  a  sine  qua  non. 

Of  the  role  played  by  mental  insufficiency  in  the 
genesis  of  tic  we  shall  have  much  to  say  later.  The 
point  we  are  desirous  of  emphasising  now  is  that 
the  first  manifestations  of  tic  have  their  origin  in,  and 
are  dependent  on,  cortical  activity,  at  least  in  a 
majority  of  cases. 

Notwithstanding  painstaking  investigation,  deter- 
mination of  the  initial  cause  may  no  doubt  be  difficult 
in  some  instances,  owing  to  the  patient's  ignorance  or 
f orgetfulness ;  for  that  matter,  the  observer  may  not 
know  how  to  set  about  his  task.  Prolonged  interroga- 
tion, however,  and  due  consideration  of  the  patient's 
environment,  will  generally  enable  him  to  reconstruct 
the  pathogeny  of  the  condition. 

It  has  been  our  practice  for  some  years  now  to 
examine  with  especial  care  into  the  mode  of  onset, 
and  to  scrutinise  the  reasons  for  the  particular  localisa- 
tion, of  any  given  tic ;  and  we  have  been  able,  in 
practically  every  case,  to  rediscover  the  exciting  cause, 
and  consequently  to  explain  the  form  taken  by  the  tic 
in  its  earliest  manifestations  as  a  voluntary  response  to 
the  stimulus.  Time  may  have  distorted  the  original 
movement,  but  a  little  patient  analysis  will  facilitate  its 
recognition  even  in  the  caricature  made  of  it  by  the  tic. 

4 


SO  TICS  AND    THEIR    TREATMENT 

A  few  concrete  instances  will  help  us  better  to 
understand  the  nature  of  this  psycho-physiological 
mechanism. 

An  individual  is  wearing  a  collar  too  small  for  him, 
and  its  frayed  edge  chafes  his  skin ;  the  neck  is  at  once 
abruptly  inclined  away  from  the  irritating  point — a 
simple  spinal  reflex  movement  of  defence.  Now  that 
h,e  is  warned  by  the  sensation  of  pain,  he  wishes  to 
avoid  it,  which  he  does  by  bending  his  head  to  the 
opposite  side.  The  act  is  similar  to  the  preceding,  but 
of  a  totally  different  nature  ;  it  is  voluntary,  not  in- 
voluntary; cortical,  not  bulbo-spinal. 

Next  day  the  collar  is  replaced  by  another  of 
ampler  proportions.  There  is  no  further  irritation 
of  the  skin,  and  accordingly  no  occasion  for  deviation 
of  the  head.  Memory  of  the  disagreeable  sensation 
may  perhaps  incite  him  to  verify  the  disappearance 
of  the  irritation  by  a  few  movements  of  the  head, 
and  in  the  normal  individual  the  matter  ends  there. 
Even  should  the  idea  of  repeating  the  gesture,  now 
become  meaningless,  occur  to  him,  he  banishes  it  by 
an  effort  of  the  will. 

With  the  candidate  for  tic  things  pass  in  quite  a 
different  fashion.  Uncalled  for  though  it  be,  he  per- 
forms the  brusque  movement  of  yesterday  perhaps  with 
a  view  to  satisfying  himself  that  the  pain  is  non- 
existent, but  he  is  not  thus  satisfied.  He  does  not  limit 
his  experiments  to  one  or  two  attempts.  He  repeats 
it  frequently  and  complacently.  The  original  source 
of  irritation  is  gone;  the  movement  intended  at  first 
to  relieve  it  persists.  Soon  the  whole  trouble  is  for- 
gotten, but  the  reiterated  gesture  becomes  habitual  and 
automatic;  it  may  have  been  rational  yesterday,  but 
to-day  it  is  superfluous,  if  not  actually  prejudicial; 
it  is  a  tic.  In  its  evolution  the  cortex  has  had 
a  part,  and  the  very  untimeliness  of  this  cortical 


THE  PATHOGENY  OF  TIC  51 

intervention  indicates  a  certain  disorder  of  psychical 
function. 

Or  again:  a  speck  gets  under  my  eyelid,  and  I 
wink — a  spasmodic  act  independent  of  the  cortex.  The 
ss  speck  is  removed,  but  the  conjunctiva  remains  a  little 
tender,  and  I  wink  again — still  only  a  spasm.  All  trace 
of  irritation  vanishes,  yet  the  blinking  persists:  it  is 
degenerating  into  a  tic. 

Wherein  consists  the  role  played  by  the  cortex  in 
the  production  of  such  phenomena?  It  intervenes  to 
order  the  repetition  of  the  gesture  provoked  involun- 
tarily, in  the  first  instance,  by  peripheral  excitation : 
and  though  one  may  not  always  be  able  later  to  dis- 
cover evidence  of  this,  one  must  at  the  least  recognise 
the  fact  that  the  mere  inopportune  persistence  of  the 
movement  bears  witness  to  psychical  imperfection. 

It  has  been  remarked  by  Gruinon  that  patients  suffer- 
ing from  tics  of  blinking  attribute  them  to  the  presence 
of  foreign  bodies  ;  he  declares,  however,  that  "  if  they 
bear  a  superficial  resemblance  to  simple  tic,  they  differ 
widely  in  essential  characters  and  from  the  point  of 
view  of  prognosis.  They  are  really  involuntary  move- 
ments of  reflex  origin,  occasioned  by  abnormal  sensa- 
tions, usually  of  pain."  He  cites  as  a  typical  instance 
the  "  tic  douloureux  "  of  the  face. 

The  description  is  strictly  accurate  provided  the 
pain  continue  ;  such  acts  are  not  tics,  they  are  spasms. 
On  the  other  hand,  the  perpetuation  of  the  move- 
ment in  the  absence  of  all  exciting  cause  and  pain 
constitutes  it  a  tic.  In  this  way  a  spasm  may  be  the 
forerunner  of  a  tic,  and  in  many  cases  no  doubt  a 
purely  spasmodic  motor  reaction  may  determine  the 
.form  and  localisation  which  the  latter  will  adopt ;  but, 
eras  we  have  said,  its  first  manifestation  is  usually  a 
'^-Voluntary  act  of  definite  causation,  and  directed  to  the 
^ 'accomplishment  of  a  definite  object. 


LI  a  R  A  r?  v 


XA*UAL  AHfS  •  .  :  H;    ;t 

SANTA  BAV!>A,?.\.  CALIFORNIA 


52  TICS  AND   THEIR    TREATMENT 

The  candidate  for  tic  is  mentally  unstable.  In- 
different perhaps  to  acute  suffering,  he  may  become 
entirely  preoccupied  by  some  trifling  sensation  of 
pain  or  by  some  source  of  petty  annoyance,  to  rid 
himself  of  which  he  will  resort  to  all  sorts  of  tricks 
and  assume  all  sorts  of  odd  attitudes — tic  germs  quick 
to  develop  in  suitable  soil. 

In  many  motor  reactions  of  the  class  we  are  now 
considering  the  main  object  is  the  avoidance  of  some 
abnormal  sensation,  suppression  of  which,  however, 
brings  no  relief  to  the  patient's  mind.  He  dreads  its 
reappearance ;  he  must  assure  himself  of  its  absence. 
He  taxes  his  ingenuity  in  the  attempt  to  rediscover 
the  sensation,  and  multiplies  his  gestures  and  attitudes 
until  once  again  he  experiences  it.  The  satisfaction 
he  felt  originally  in  shunning  the  pain  or  the  dis- 
comfort is  paralleled  by  the  satisfaction  he  now  knows 
in  its  rediscovery.  In  each  instance  the  motor  phe- 
nomena are  voluntary  and  co-ordinated,  but  their 
excessive  repetition  betrays  unstable  mental  equilibrium. 

Instructive  examples  of  this  pathogenic  process 
are  furnished  by  the  history  of  0.,  and  by  the  case 
of  a  young  patient  J.,  from  which  we  extract  the 
following  : 

In  1896,  during  the  holidays,  a  tic,  secondary  to  some  slight  nasal 
ulceration,  made  its  appearance.  The  child  learned  the  trick  of 
wrinkling  its  nose  and  of  puckering  its  upper  lip,  sometimes  attempting 
by  various  facial  grimaces  to  lessen  the  irritation  due  to  the  little 
nasal  sore,  sometimes,  on  the  contrary,  finding  delight  in  deliberately 
seeking  the  unusual  sensation.  The  sniffing  soon  became  involuntary, 
and  for  the  next  two  months,  long  after  the  ulceration  was  healed,  this 
nasal  tic  continued. 

Then  another  cause  came  into  operation,  occasioning  a  new  gesture 
and  entailing  a  new  tic.  Cracking  of  the  labial  mucous  membrane  during 
winter  led  to  incessant  licking  and  nibbling  at  the  roughened  surface. 
With  the  first  excoriation  the  patient  proceeded  to  moisten  his  lips  with 
his  tongue,  whence  fresh  cracks,  followed  by  the  renewal  of  nibbling  and 
licking  movements. 


THE  PATHOGENY  OF  TIC  53 

In  March,  1899,  after  a  severe  attack  of  influenza  accompanied  by  fever 
and  pains  in  the  joints,  he  began  to  complain  of  stiffness  and  a  sort  of 
cracking  in  the  neck,  disagreeable  rather  than  painful.  To  avoid  this, 
or  to  reproduce  it — as  one  sometimes  amuses  oneself  by  "  cracking  one's 
joints  " — he  quickly  learned  to  make  all  sorts  of  bizarre  head  movements, 
and  so  a  tic  of  the  neck  started  which  lasted  several  months. 

Noir  has  directed  attention  to  a  tio  of  frequent 
occurrence  among  amaurotic  idiots,  consisting  in  rapid 
to-and-fro  movements  of  the  finger  before  the  eyes. 
The  explanation  seems  to  be  that  their  blindness  is 
not  absolute  enough  to  prevent  some  faint  appreciation 
of  light  by  retinal  stimulation,  and  the  effect  of  the 
luminous  impression  is  enhanced  by  the  alternation 
of  light  and  shade  sensations  produced  by  the  waving 
of  the  fingers  in  front  of  the  eyes.  The  tic  is  neither 
more  nor  less  than  a  search  after  this  effect. 

Another  case  in  point  is  reported  by  Dubois  l : 

The  patient  is  a  young  woman  twenty  years  old  who  has  acquired 
the  habit  of  beating  her  right  elbow  against  her  chest  fifteen  or  twenty 
times  a  minute,  until  it  happens  to  impinge  with  rather  greater  violence 
on  a  whalebone  in  her  corset  ;  this  is  accompanied  by  a  slight  guttural 
cry.  It  would  appear  the  sole  satisfaction  in  her  tic  is  in  the  attainment 
of  this  object,  since  it  is  succeeded  by  temporary  cessation  of  the  movements. 
Their  constant  repetition  has  caused  an  insignificant  erosion  of  the  skin 
over  a  limited  area  on  the  elbow,  and  it  is  only  when  this  particular  spot 
is  touched  that  the  ejaculation  is  uttered  and  the  tic  arrested.  If  the 
elbow  be  at  rest,  the  head  is  inclined  from  left  to  right  several  times 
a  minute. 

Evidently,  then,  in  the  subjects  of  tic  the  impulse 
to  seek  a  sensation  is  of  very  common  occurrence,  as 
is  also  the  impulse  to  repeat  to  excess  a  functional  act. 
It  is  precisely  this  exaggerated  and  inopportune  multi- 
plication of  movement  that  is  pathological. 

The  mother  of  one  of  Noir's  patients  was  always 
tempted  to  repeat  any  simple  purposive  movement 

1  DUBOIS,  "  Traitement  des  tics  convulsifs  par  la  reeducation  des 
centres  moteurs,"  Bulletin  general  de  therapie,  April  30,  1901 


54  TICS   AND    THEIR   TREATMENT 

that  she  had  made  a  moment  before,  even  though  the 
reason  for  the  act  no  longer  existed. 

The  imperiousness  of  these  impulses,  and  the 
peculiar  relief  attendant  on  submission  to  them,  ac- 
centuate the  closeness  of  the  resemblance  between 
tic  and  obsession,  to  which  reference  will  be  made 
later ;  but  it  is  necessary  at  this  early  stage  to  indicate 
the  bearing  of  these  psychical  phenomena  on  the 
pathogeny  and  diagnosis  of  tic. 

Many  of  the  conditions  with  which  we  are  dealing 
are  characterised  in  addition  by  an  emotional  element. 
Dupre 1  believes  an  emotional  shock  is  the  exciting 
cause  of  tic,  as  it  sometimes  is  of  obsessions. 

Apropos  of  this  view,  we  may  quote  again  from  the 
history  of  the  young  patient  J. : 

During  his  holidays  he  improved  sufficiently  to  enable  him  to  resume 
his  classes,  but  another  attack  of  influenza  in  the  beginning  of  1900 
was  the  occasion  of  a  relapse.  He  began  to  complain  of  overpowering 
fatigue  ;  became  depressed  and  morbidly  anxious  about  his  future  ;  had 
attacks  of  hysterical  sobbing  ;  suffered  great  mental  anguish,  accompanied 
by  flushing  and  profuse  perspiration  ;  in  short,  he  fell  into  a  veritable 
state  of  mal  obudant. 

At  the  same  time,  the  slightest  pain  or  annoyance  was  a  pretext  for 
his  tics  to  exhibit  themselves  with  redoubled  vigour.  Even  the  mere 
idea  of  his  tics,  the  fear  of  them,  incited  him  further  in  the  same 
direction.  He  seems  then  to  have  set  himself  to  invent  new  movements, 
and  forgetting  forthwith  that  he  himself  was  their  creator,  became 
alarmed  at  them  as  sure  signs  of  the  aggravation  of  his  disease. 

Analogous  details  will  be  found  in  all  cases  which 
have  been  studied  as  well  from  the  mental  as  from 
the  physical  side.  For  our  part,  we  consider  a  tic 
cannot  be  a  tic  unless  it  be  associated  with  a  certain 
degree  of  mental  instability  and  imperfection,  indubit- 
able evidence  of  which  is  furnished  by  a  psychical 
abnormality  of  constant  occurrence  in  this  malady— viz. 
anomalies  of  volition. 

1  DUPRE,  Soc.  de  neur.  de  Paris,  April  18,  1901. 


THE  PATHOGENY  OF   TIC  55 


TIC    AND    WILL 

It  might  be  imagined  that  a  tic  would  cease  to  exist 
as  such  were  a  voluntary  element  to  enter  into  its 
constitution.  The  fact,  however,  that  tic  is  the  sequel 
to  frequent  repetition  of  a  primarily  voluntary  act,  and 
that  it  may  be  arrested,  transformed,  or  aborted,  is 
proof  to  the  contrary  of  which  there  is  no  gainsaying. 

The  truth  is,  once  a  tic  is  established,  it  has  all 
the  appearance  of  an  involuntary  movement,  but  that 
nevertheless  its  manifestations  may  be  either  modified 
or  inhibited  by  an  effort  of  the  will  is  patent  from 
clinical  observation.  This  is  a  fact  of  great  importance. 

Spasm  knows  no  control  (says  Brissaud).  Nothing  will  arrest  the 
bolus  of  food  as  it  passes  into  the  pharynx,  unless  by  the  inversion  of 
the  whole  function  of  deglutition.  ...  As  regards  tic,  however,  inhibition 
is  possible  because  the  phenomenon  is  cortical.  In  almost  every  case, 
reinforcement  of  the  will  can  momentarily  at  least  check  it. 

Consensus  of  opinion  admits  diminution  of  will 
power  to  be  the  cardinal  mental  symptom  of  the  tic 
patient.  Inhibitory  insufficiency,  as  Blocq  and  Onanoff 
say,  allows  the  persistence  of  fixed  ideas  of  movement 
which  reveal  themselves  by  involuntary  acts.  Noir 
has  admirably  supplemented  the  researches  of  Bibot 
in  this  direction : 

The  infant's  activity  is  purely  reflex,  and  manifested  by  a  profusion 
of  movements,  to  suppress  or  restrain  the  majority  of  which  is  the  task 
of  education.  It  is  highly  probable  that  any  co-ordinated  tic  whose 
evolution  can  be  traced  at  all  has  its  origin  in  the  infant's  spontaneous 
muscular  play.  From  this  point  of  view  the  frequency  of  these  movements 
in  idiots  is  readily  explicable,  since  their  intellectual  development  never 
gets  beyond  the  stage  of  childhood.  The  more  confirmed  the  idiocy  and 
the  more  rudimentary  their  mind,  the  more  prone  are  their  tics  to  be 
complex  and  inveterate. 

These  remarks  are  pertinent  to  the  case  not  only 


56  TICS  AND    THEIR    TREATMENT 

of  idiots,  imbeciles,  or  backward  children,  but  of  all 
the  subjects  of  tic.  In  them  some  degree  of  mental 
infantilism  is  of  invariable  occurrence.  The  tic  patient 
has  the  weak  and  capricious  will  of  the  child  ;  young 
or  old,  he  does  not  know  how  to  will ;  if  his  willing 
be  sometimes  excessive,  it  is  never  resolute.  Were  it 
otherwise,  he  might  control  his  meaningless  gestures, 
but  his  efforts  are  both  feeble  and  ephemeral. 

TIC   AND    HABIT 

The  view  which  regards  tic  as  a  "  pathological 
muscular  habit"  provides  emphatic  illustration  of  the 
sinister  influence  of  volitional  infirmity. 

This  aspect  of  the  question  is  of  deep  significance. 
If  we  define  a  habit,  in  the  words  of  Littre,  as  a 
"  disposition  acquired  by  the  repetition  of  the  same 
acts,"  we  can  easily  conceive  how  intimate  is  the 
relation  between  habit  and  automatism,  and  how  con- 
stant rehearsal  of  the  same  movement  in  the  same 
manner  will  create  a  mode  of  motor  reaction  independent 
of  the  function  of  the  will.  It  has  been  made  clear 
already  that  the  phenomena  of  tic,  regarded  from  the 
motor  standpoint,  reveal  an  identical  process  at  work ; 
but  the  fundamental  difference  between  the  habits  of 
normal  individuals  and  those  of  tic  subjects  is  that  the 
former  can  be  checked  or  modified  by  voluntary  effort, 
whereas  the  latter  gradually  acquire  the  pathological 
features  of  tenacity  and  irresistibility. 

In  a  typical  case  of  tic  (says  Duprc)1  the  establishment  of  a  reflex 
sensorimotor  diastaltic  arc,  vii  the  cortex,  between  peripheral  stimuli  of 
whatever  nature  and  corresponding  muscular  reaction,  is  a  sign  that 
predisposition  has  changed  the  physiological  to  the  pathological,  and 
transformed  a  habit  into  a  tic. 

Guinon  argues,  however,  that  tic  ought  not  to  be 
1  DUPRE,  loc.  dt. 


THE  PATHOGENY  OF  TIC  57 

cited  in  the  catalogue  of  diseases,  since  it  is  ultimately 
a  deep-rooted " bad  habit"  only,  not  a  pathological  fact. 
We  are  not  prepared  to  maintain,  of  course,  that 
all  motor  "  bad  habits  "  are  tics,  for  a  whole  host  of 
familiar  gestures,  tricks,  and  mannerisms  do  not  merit 
the  name,  superfluous  and  even  detestable  though  they 
may  be.  It  is  true  they  are  the  product  of  education, 
and  become,  since  the  will  has  less  and  less  to  do 
with  their  appearing,  at  the  last  purely  automatic ;  they 
may  thus  developmentally  bear  a  close  resemblance 
to  tics.  As  Letulle  says  : 

The  infant  who  is  constantly  sucking  its  thumb,  the  individual 
who  never  ceases  picking  his  teeth,  or  rubbing  his  eyes,  or  lips,  or  chin, 
or  ear,  who  is  for  ever  scratching  his  head  or  his  beard — all  have 
no  doubt,  originally,  been  driven  to  the  repetition  of  the  trick  by 
some  real  necessity  in  the  shape  of  dental  caries,  or  ciliary  blepharitis,  or 
pityriasis  capitis  ;  but  removal  of  the  cause  is  not  followed  by  cessation 
of  the  gesture.  A  man  will  learn  the  habit  of  perpetually  smoothing 
his  hair,  and  will  not  desist  from  his  favourite  trick  though  he  become 
absolutely  bald. 

But  such  automatic  habits  and  mannerisms  are 
not  genuine  tics  so  long  as  the  movement  executed 
conserves  in  form  the  characters  of  a  normal  gesture. 
Be  it  never  so  inopportune  or  absurd,  it  is  not  a  tic. 
It  comes  rather  under  the  heading  of  stereotyped  acts, 
whose  kinship  with,  and  difference  from,  the  tics,  have 
been  well  demonstrated  by  Seglas. 

While  the  stereotyped  act  has  all  the  appearance 
of  a  normal  movement,  the  tic,  on  the  contrary, 
is  a  "  corrupt "  muscular  contraction ;  its  subject  is 
irresistibly  impelled  to  its  performance,  and  any  attempt 
at  repression  is  painful,  sometimes  even  agonising. 
Victory  is  perhaps  not  entirely  impossible,  but  any 
arrest  is,  as  a  rule,  only  temporary,  and  entails  suffer- 
ing which  well  deserves  to  be  considered  patho- 
logical. 


58  TICS  AND    THEIR    TREATMENT 

On  the  other  hand,  the  thousand  illogical  and  absurd 
mannerisms  of  which  we  have  been  speaking  betray  no 
irresistible  imperiousness  in  their  execution,  and  require 
no  agonising  struggle  for  their  repression.  They  are 
not  tics.  The  crucial  point  in  the  differential  diagnosis 
is  the  presence  or  absence  of  mental  suffering. 

The  distinction  may  be  further  elaborated.  Con- 
centration of  the  attention  may  diminish  the  intensity 
or  even  inhibit  the  occurrence  of  a  tic ;  inversely,  a 
simple  bad  habit  is  manifested  preferably  during 
this  very  concentration.  In  the  heat  of  physical  or 
intellectual  labour,  we  have  all  our  favourite  and 
characteristic  tricks:  we  curl  our  moustache,  we  twist 
our  beard,  we  scratch  our  forehead,  we  rub  our  chin, 
we  nod  our  head,  we  fidget  with  our  fingers  in  reading, 
speaking,  reciting — in  any  mental  or  physical  exercise 
requiring  our  attention  we  reveal  innumerable  little 
oddities  of  movement ;  but  let  our  thoughts  be  directed 
for  an  instant  to  these  gestures  of  distraction,  and 
they  disappear  forthwith,  to  reappear  afresh  when  we 
are  absorbed  in  our  work  again.  Charcot  used  to  twist 
his  hair  round  his  index  finger  so  intricately  that  to 
disentangle  the  finger  one  day  a  lock  of  hair  had 
actually  to  be  cut  off.  It  was  a  trick  of  his,  not  a  tic. 

In  the  case  of  the  latter,  leisure  of  mind  and  body 
is  the  signal  for  the  apparition  of  the  inopportune 
movements.  Any  form  of  effort  demanding  the  attention 
will,  as  a  general  rule,  lessen  their  frequency  or  abolish 
them  altogether. 

Trousseau  quotes  the  case  of  a  young  girl  afflicted 
with  severe  tic  who  could  play  through  any  piece  on 
the  piano  without  the  slightest  interruption.  Guinon 
similarly  has  known  cases,  one  of  whom  could  juggle 
accurately  with  knives,  and  another  whose  infirmity  did 
not  prevent; her  from  taking  a  successful  part  in  operatic 
ballet.  Young  L.  is  passionately  fond  of  dancing, 


THE  PATHOGENY  OF  TIC  59 

but  lie  never  tics  in  the  ballroom.  0.  is  an  excellent 
amateur  billiard  player  and  never  handicapped  by  his 
tic  when  playing,  or,  for  that  matter,  when  fishing 
or  fencing ;  but  if  his  attention  be  not  thus  absorbed, 
it  is  only  with  the  utmost  difficulty  that  he  can  master 
his  tic. 

We  all  have  met  the  young  man  who  cannot  strike 
a  ball  at  tennis  without  protuding  his  tongue  at 
the  same  moment;  his  partner  bites  his  lips  at  any 
difficult  stroke.  At  other  times  neither  betrays  the 
slightest  grimace  ;  neither  is  conscious  of  any  effort 
in  maintaining  repose.  The  occurrence  of  these  move- 
ments during  active  concentration  of  the  attention,  and 
the  absence  of  either  difficulty  or  distress  in  checking 
them,  justify  their  classification  as  stereotyped  acts, 
in  subjects  psychically  normal. 

Tic  is  a  pathological  habit,  to  use  Brissaud's  phrase, 
and  its  description  as  a  habit  disease  is  in  harmony 
with  the  facts.  We  must  expect,  of  course,  to  meet 
every  intermediate  variety  between  the  bad  habit 
and  the  true  tic,  but  this  need  not  deter  us  from 
drawing  the  above-noted  distinction,  the  application 
of  which  will  be  found  not  without  value  in  the  great 
majority  of  instances. 

TIC   AND    IDEA 

As  we  have  already  seen,  a  peripheral  stimulus  may 
originate  a  cortical  reflex  whose  expression  is  a  motor 
reaction,  or  the  reaction  may  take  place  where  the 
stimulus  is  entirely  cortical;  in  other  words,  an  idea 
may  be  the  starting-point  of  a  movement  which  may 
in  its  turn  degenerate  into  a  tic.  All  that  has  been 
already  said  of  these  phenomena  is  applicable  to  this 
movement  of  ideational  origin.  It  too  will  be  trans- 
formed into  a  tic  when  it  is  repeated  without  exciting 


60  TICS  AND   THEIR   TREATMENT 

cause  and  for  no  definite  end,  when  its  reiteration 
becomes  imperious  and  irresistible,  its  suppression  accom- 
panied with  malaise  and  its  execution  with  relief. 

Tics  of  this  sort  are  numerous  enough.  "  To  think 
an  act,"  as  Charcot  used  to  say,  following  Herbert 
Spencer  and  Bain,  "  is  already  to  accomplish  it.  When 
we  think  of  the  movement,  say  of  extension  of  the 
hand,  we  have  already  sketched  it  in  our  minds;  and, 
should  the  idea  be  too  strong,  we  execute  it." 

In  this  connection  Grasset  most  appropriately  cites 
the  fact  that  the  peoples  of  mid-France  evince  a 
peculiar  aptitude  for  mimicking  by  suitable  gesture 
the  various  ideas  which  occur  in  the  course  of  conver- 
sation. "  You  will  always  succeed,"  he  says,  "  with  the 
following  little  experiment.  In  a  drawing-room  ask 
ten  individuals  consecutively  to  tell  you  what  a  rattle 
(crtcelle)  is.  The  answer  will  in  every  case  be  accom- 
panied by  a  gesture  expressive  of  an  object  that  turns. 
To  think  an  act  is  already  to  perform  it ;  the  thought 
and  the  gesture  are  wellnigh  inseparable." 

The  truth  of  this  observation  is  not  a  question  of 
geography.  Examples  are  met  with  on  every  hand. 
It  is  a  law,  abundant  evidence  for  which  is  furnished 
by  all  who  tic.  But  however  exuberant  be  accom- 
panying movements  of  explanation,  they  must  present 
the  additional  features  of  inappositeness  and  irresisti- 
bility to  be  denominated  tics. 

A  case  that  has  come  under  our  own  notice  is  worth 
mentioning  because  of  its  peculiarity  and  instructiveness. 
The  patient  was  an  artistic,  well-educated,  and  well- 
travelled  man,  gifted  to  a  remarkable  degree  with  the 
faculty  of  assimilation.  Apart  from  genuine  tics  in 
the  shape  of  sudden  jerks  of  face,  arm,  or  leg,  he  had 
acquired  the  trick  of  accompanying  his  conversation 
with  a  peculiar  mimicry  of  its  content.  Not  satisfied 
with  providing  a  gesture  for  nearly  every  word,  he 


THE  PATHOGENY  OF  TIC  61 

divided  the  words  themselves  into  syllables  for  each 
of  which  he  had  an  appropriate  action,  whence  arose  a 
series  of  mimicry  puns  of  most  unexpected  effect. 

For  instance,  during  the  enunciation  of  the  following 
sentence,  "  We  were  on  a  paddle  steamer,  with  captain, 
commissaire,  and  doctor,"  he  first  of  all  imitated  the 
movement  of  paddles ;  he  then  put  his  hand,  with  three 
fingers  apart,  to  his  forehead  (the  captain's  cap  has 
three  lace  bands) ;  to  mimic  the  word  commissaire  he 
shook  hands  with  himself  (commissaire — comme  U  serre) ; 
to  express  the  word  doctor  he  pretended  to  touch 
imaginary  breasts  on  his  body  (mededn — mes  deux  seins) ; 
and  so  on  throughout  all  his  conversation. 

Voluntary  execution  of  these  puns  had  been  suc- 
ceeded by  complete  automatism,  yet  they  were  not  tics, 
because,  however  singular  the  mimicry,  it  was  appro- 
priate ;  whereas  his  facial  grimaces,  the  shrugging  of 
his  shoulders,  the  tapping  of  his  heels,  repeated  every  \ 
minute  for  no  reason  or  purpose,  were  real  tics. 

If,  when  asked  what  a  rattle  is,  we  make  a  turning 
movement  with  our  hand,  or  if  when  asked  to  explain 
the  word  braTidebourg  we  indicate  an  imaginary  arrange- 
ment of  braid  on  our  coat — these  two  experiments 
always  succeed — we  are  attempting  to  express  an  idea 
by  mimicry  at  the  actual  moment  of  its  arising  in  the 
mind ;  but  the  subject  of  a  tic — which  may  primarily 
have  been  the  representation  by  mimicry  of  an  idea 
— continues  the  gesture  long  after  the  idea  which 
provoked  it  has  vanished. 

A  woman  speaking  with  animation  at  a  telephone 
will  make  with  face  or  hand  a  thousand  useless 
gestures,  useless  since  her  friend  cannot  see  them,  but 
they  are  not  tics,  even  though  they  may  be  justly 
described  as  functional,  automatic,  superfluous,  and  in- 
opportune. If  we  are  normally  constituted,  we  betray 
a  pleasant  idea  by  a  smile,  we  express  our  conviction 


62  TICS  AND   THEIR    TREATMENT 

by  an  appropriate  gesture  of  affirmation  ;  if  we  smile 
or  gesticulate  with  no  motive  for  doing  either,  we  have 
begun  to  tic.  It  is  not  sufficient  that  the  act  be  un- 
timely at  the  moment  of  execution;  we  must  be  per- 
suaded that  it  no  longer  stands  in  any  relation  to  the 
idea  which  called  it  forth  at  the  first,  and  that  its 
repetition  is  excessive,  its  inappositeness  constant,  its 
performance  urgent,  and  its  inhibition  transient,  before 
we  can  say  it  is  a  tic. 

Should  the  cortex  be  functioning  harmoniously, 
afferent  impulse  and  efferent  reaction  stand  in  due 
proportion  one  to  the  other ;  but  any  disturbance  of 
psychical  equilibrium — e.g.  the  fixity  of  some  idea 
combined  with  inhibitory  weakness — will  effect  a  corre- 
sponding disturbance  on  the  motor  side.  Charcot  used 
to  speak  of  tics  of  the  mind  revealing  themselves 
by  tics  of  the  body.  Fear  may  elicit  a  movement  of 
defence,  to  persist  as  a  tic  after  the  exciting  cause  has 
vanished. 

It  is  of  course  quite  incorrect  to  say  that  each  and 
every  motor  reaction  to  a  pathological  idea  is  a  tic.  The 
psychasthenic  who  in  his  fear  of  draughts  shakes  the 
door-knob  a  hundred  times  a  day  to  make  sure  the  door 
is  shut,  is  not  a  martyr  to  tic ;  in  spite  of  the 
absurdity  of  his  action,  it  is  logically  connected  with  the 
idea  that  originated  it,  and  it  is  the  idea  which  is  absurd. 
To  make  an  involuntary  movement  of  defence  against 
some  purely  imaginary  ill,  on  the  other  hand,  and  to 
continue  when  all  fear  is  past,  is  to  tic. 

In  practice  it  may  not  always  be  a  simple  matter 
to  uphold  the  distinction,  but  some  such  demarcation  of 
the  tic's  limits  is  called  for  if  we  are  to  avoid  its  being 
applied  to  any  act  performed  under  the  compulsion  of  a 
pathological  mental  state. 

In  its  mildest  form  the  mental  trouble  may  consist  of 
an  ordinary  psychomotor  hallucination,  but  if  it  be  not 


THE  PATHOGENY  OF   TIC  63 

projected  as  an  objective  phenomenon  it  does  not  deserve 
to  be  called  a  tic.  One  of  Seglas's  patients  met  a  choreic 
woman  undergoing  electrical  treatment  in  the  same 
room  as  herself ;  on  leaving  she  felt  as  though  her  own 
right  arm  were  the  seat  of  spasmodic  movements  similar 
to  those  of  the  choreic  patient,  but  as  they  did  not 
betray  themselves  by  any  external  sign  they  cannot  be 
considered  tics. 

The  exteriorisation  of  the  hallucinatory  phenomenon 
suffices  at  once  to  bring  it  within  the  scope  of  our 
definition.  Innumerable  tics  arise  in  this  way,  provoked^ 
mayhap,  by  some  or  other  insignificant  psychomotor 
hallucination.  The  attitude  adopted  by  certain  patients, 
as  remarked  by  Seglas,  is  an  index  to  the  nature  and 
seat  of  their  hallucinations.  Some  keep  their  tongue 
firmly  bitten  between  the  teeth  ;  others  cram  their  mouth 
with  pebbles,  or  compress  their  epigastrium  tightly, 
under  the  impression  that  it  is  the  source  of  their  voice. 
Should  such  gestures  persist  while  the  hallucination 
does  not,  they  may  give  rise  to  what  we  are  in  the 
habit  of  calling  "  tonic  tics,"  or  "  tics  of  attitude,"  but 
we  must  repeat  that  the  presence  of  a  convulsive 
element  is  essential;  however  out  of  place  or  absurd  the 
contractions  are,  if  otherwise  they  are  normal  we  are 
dealing  with  what  Seglas  designates  stereotyped  acts. 
To  this  question  we  shall  return  later. 

TIC  AND  CONSCIOUSNESS 

According  to  Guinon,  proof  that  "  convulsive  "  tic 
is  conscious  is  furnished  by  the  accurate  description  and 
rational  explanation  patients  supply  of  their  affliction. 
Similarly  Letulle's  "  co-ordinated  "  tic  is  a  conscious  act, 
at  least  in  its  commencement;  it  is  a  "bad  habit"  which 
finally  passes  beyond  the  limit  of  consciousness. 

Now,  while  no   doubt  most  subjects  show  a  keen 


64  TICS  AND    THEIR   TREATMENT 

appreciation  of  their  tic  when  their  attention  is  directed 
to  it,  they  are  none  the  less  unconscious  of  it  at 
the  moment  of  its  manifestation.  This  is  the  ground 
on  which  Letulle  bases  his  statement  that  all  tics, 
of  whatsoever  variety,  are  habitually  outside  the 
domain  of  consciousness.  To  this  fact  so  much  im- 
portance has  been  attached  that  the  attempt  has  been 
made,  more  especially  by  Blocq  and  Onanoff,1  to  differ- 
entiate the  conscious  from  the  unconscious  tic. 

In  our  opinion,  the  distinction  is  ambiguous  and 
tends  needlessly  to  complicate  our  ideas  on  the  subject. 
The  patient  with  "  convulsive  "  tic  is  conscious  of  it  in 
the  sense  that  he  is  well  aware  of  its  existence,  yet  how 
can  the  gesture  be  a  conscious  one  if  it  is  synchronous 
with  mental  preoccupation  ?  On  the  other  hand,  the 
patient  with  "  co-ordinated  "  tic  may  bite  his  lips  un- 
consciously, but  he  is  by  no  means  ignorant  of  his  little 
failing. 

This  divergence  of  opinion  depends  entirely  on  the 
possibility  of  regarding  the  phenomena  at  different 
moments  during  their  production.  The  subject  is  in 
a  position  to  appreciate  his  state  both  before  and  after 
the  tic,  not  during  it.  In  a  sense  it  may  be  said  that 
tic  is  alternately  conscious  and  unconscious,  in  which 
respect  it  is  comparable  to  the  obsession ;  the  close 
analogy  between  the  two  conditions  we  shall  indicate 
more  fully  later.  As  a  matter  of  fact,  the  same  holds 
true  for  every  variety  of  spasm. 

"We  are  not  disposed  to  introduce  here  a  term  sacred 
to  the  psychologist  and  to  speak  of  the  tic  as  subcon- 
scious. Pierre  Janet  does  not  admit  the  absolute 
unconsciousness  of  habit;  even  when  the  latter  has 
degenerated  into  a  tic,  it  is  not  outwith  the  realm  of 
consciousness.  "We  prefer  not  to  venture,  however,  into 
the  perilous  region  of  the  subconscious,  in  spite  of  our 
1  BLOCQ  and  ONANOFF,  Maladies  nerveuses,  1892. 


THE  PATHOGENY  OF  TIC  65 

appreciation  of  the  happy  results  attributable  to  its 
careful  and  discerning  exploration  by  observers  such,  as 
Janet  himself. 

According  to  Cruchet,  certain  so-called  psychical  tics 
are  always  subliminal — for  instance,  the  imitation  tics 
common  in  children  and  in  idiots. 

But  if  the  consciousness  of  the  normal  adult  be,  as 
it  admittedly  is,  a  most  elusive  conception  to  define, 
how  infinitely  more  precarious  is  the  task  in  the  case 
of  idiots  or  infants  !  Cruchet  says  it  is  impossible  to 
be  sure  whether  at  any  given  moment  a  tic  has  been 
above  the  threshold  of  consciousness  or  not ;  and  we 
do  not  think  the  question  will  be  elucidated  by  the 
introduction  of  data  so  difficult  to  comprehend  as  the 
consciousness,  unconsciousness,  or  subconsciousness  of 
the  tic  patient.  In  any  case,  these  conceptions  are  quite 
inadequate  for  the  establishment  of  useful  distinctions. 
All  that  we  can  say  is  that  the  participation  of  con- 
sciousness in  the  phenomena  of  tic  varies  in  time  and 
degree.  To  hazard  farther  would  be  to  invite  disaster. 

TIC  AND  POLYGON 

The  proposal  has  been  made  by  Grasset  to  apply 
his  attractive  hypothesis  of  the  cortical  polygon  to 
the  interpretation  of  the  pathogenesis  of  tic.  It  is 
desirable,  first  of  all,  to  recall  briefly  the  significance 
of  the  word  polygon  in  the  sense  adopted  by  that 
neurologist.1 

At  the  central  end  of  the  physiological  ladder  is  the  superior  or 
cortical  system  of  perception  neurons  whose  cells  form  the  grey  matter 
of  the  convolutions.  Physiological  and  clinical  research  necessitates  the 
subdivision  of  this  system  into  two  groups — the  neurons  of  psychical 
automatism,  and  the  neurons  of  superior  (i.e.  voluntary  or  free)  cerebra- 
tion. The  former  function  is  not  of  the  same  level  as  the  ordinary  reflex 

1  GRASSET,  Anatomic  cliniquedes  centres  nerveux,  Paris,  1900,  p.  5. 

5 


66  TICS  AND    THEIR    TREATMENT 

arc,  since  it  is  in  relation  to  co-ordinated,  intelligent,  and  in  a  sense 
conscious  acts  ;  at  the  same  time  it  is  to  be  distinguished  assiduously 
from  the  latter,  in  which  we  include  our  personality,  moral  consciousness, 
free  will,  and  responsibility. 

Activity  on  the  part  of  the  inferior  psychical  neurons  is  seen  : 

1.  In  normal  individuals — during  sleep,  dreams,  and  acts  of  distraction. 

2.  In  the  nervous — in  nightmares,  oniric  states,  table  turning,  thought 
reading,  the  use  of  the  divining  rod,  automatic  writing,  cumberlandism, 
spiritualism. 

3.  In   the   diseased — in   somnambulism,    catalepsy,    hysteria,    certain 
phenomena   of  epilepsy,    hypnotism,    double   personality  ;    also  in    some 
cases  of  aphasia,  and  in  such  conditions  as  astasia-abasia.     Every  mani- 
festation   of    this    inferior    psychism    is    characterised    by    spontaneity, 
herein   differing  from    mere   reflex    acts,    but    not    by   freedom,  which  is 
the  propre  of  superior  psychism. 

The  various  neurons  subserving  the  former  or  inferior  function  are 
cortical,  and  form  the  cortical  polygon.  Situated  at  a  higher  physiological 
level  are  those  for  the  latter  function,  united  in  what  I  designate  the 
centre  O. 

Grasset's   general   conception   of  tic  is  accordingly 
as  follows : 

In  contradistinction  to  a  pure  reflex,  a  tic  is  a  complex  or  associated 
act.  There  is,  however,  more  than  one  centre  for  the  elaboration  of 
these  complex  or  associated  acts,  notably  the  bulbo-medullary  axis,  and 
the  cerebral  polygon,  as  we  call  it.  The  former  serves  as  centre  not 
merely  for  simple  reflexes,  but  for  true  associated  acts  also,  such  as 
conjugate  deviation  of  the  head  and  eyes,  walking  movements  in  the 
decerebrate  animal,  etc. 

We  can  conceive,  then,  a  first  group  of  non-mental  tics  corresponding 
to  and  reproducing  these  movements  of  bulbo-medullary  origin.1 

Let  us  turn  now  to  our  polygon  formed  by  the  various  centres 
of  psychic  automatism.  Polygonal  reactions,  such  as  writing  or 
speaking,  exceed  both  simple  reflexes  and  bulbo-medullary  associated 
acts  in  complexity  ;  they  are  to  all  appearance  spontaneous  and  in  a 
certain  measure  intellectual,  but  they  are  neither  free  nor  conscious — 
attributes  that  distinguish  the  functions  of  the  centre  O,  the  seat  of 
the  personal,  conscious,  voluntary,  responsible  ego.  The  polygon  con- 
sists of  receptive  sensory  centres  for  hearing,  vision,  and  general  sensibility, 
and  of  transmitting  motor  centres  for  speaking,  writing,  and  various 
body  movements.  They  all  communicate  with  each  other,  with  O, 

1  GRASSET,  Lefons  de  clinique  medicale,  3rd  series,  fasc.  i.  1896, 
PP-  5»  38. 


THE  PATHOGENY  OF  TIC  67 

and  with  the  periphery,  so  rendering  possible  voluntary  modification  of 
automatic  action.  In  some  cases,  on  the  contrary,  there  may  be  a  sort 
of  dissociation  between  O  and  the  polygon,  when  the  activity  of  the 
latter  becomes  supreme,  as  during  sleep — we  dream  with  our  polygon — 
or  in  distraction. 

In  states  intermediate  between  the  physiological  and  the  pathological, 
pure  independent  polygonal  action  may  reveal  itself  in  the  remarkable 
phenomena  of  nightmare,  the  divining  rod,  table  turning,  automatic  writing, 
etc.,  while  certain  aphasias  and  agraphias,  somnambulism,  catalepsy, 
and  various  hysterical  conditions  constitute  the  pathology  of  the  polygon. 

The  fact  that  all  mental  attributes  and  functions  are  situate  in  O 
definitely  negatives,  in  my  opinion,  any  classification  in  the  category  of 
mental  diseases  of  such  conditions  as  hysteria,  so  many  of  whose  mani- 
festations are  polygonal  alone. 

Our  second  group  of  tics — polygonal  tics,  we  may  style  them — are 
correspondingly  associated,  co-ordinated,  and  psychical,  but  not  mental  ; 
they  have  nought  to  do  with  the  superior  psychism  of  O. 

Finally,  in  direct  and  strict  dependence  on  an  actual  idea  is  a  third 
group  of  tics,  the  psychical  tics  properly  so  called. 

We  have  reproduced  Grasset's  theory  in  some  detail 
since  it  is  one  of  the  two  most  recent  contributions 
to  the  study  of  the  tic's  pathogenesis.  The  other  is 
that  of  Brissaud. 

An  apparent  lack  of  harmony  between  the  rival 
hypotheses  is,  we  shall  see,  due  rather  to  a  difference 
in  the  interpretation  of  certain  terms  than  to  a  real 
opposition  of  ideas. 

Brissaud's  view  that  the  tic  is  a  co-ordinated 
automatic  act  and  consequently  cortical  is  objected  to 
by  Grasset.  Every  automatic  co-ordinated  act  is  not 
of  necessity  cortical.  Conjugate  deviation  of  the  head 
and  eyes  may  be  of  bulbar  origin  ;  certain  spinal  move- 
ments even  may  be  no  less  co-ordinated  and  automatic. 
The  decerebrate  animal's  walk  may  be  perfect  in  its 
co-ordination. 

Careful  analysis  shows  the  divergence  of  opinion 
to  arise  merely  from  a  differing  significance  attached 
to  the  word  origin.  Brissaud  is  considering  the  origin 
of  the  tic  in  time,  at  the  moment  of  its  appearance ; 


68  TICS  AND    THEIR    TREATMENT 

Q-rasset  its  origin  in  space,  at  the  seat  of  its  production. 
Once  the  tic  is  constituted,  its  repetition  each  moment 
is  a  manifestation  of  polygonal  activity,  but  it  is  none 
the  less  true  that  the  movement  which  has  degenerated 
into  a  tic  had  its  source  in  cortical,  i.e.  psychical,  activity. 
Any  one  who  appreciates  the  import  of  Grasset's 
ideas  will  readily  understand  his  terminology ;  it  is  at 
the  same  time  expedient  that  the  possibility  of  ambiguity 
in  the  use  of  words  etymologically  synonymous  should 
be  avoided.  Now,  however  judicious  be  the  distinction 
he  draws  between  psychical  and  mental,  it  is  to  be 
feared  it  is  not  always  adequately  grasped :  we  do 
not  intend,  therefore,  to  employ  either  mental  or 
psychical  tic  in  our  vocabulary,  still  less  "  psycho- 
mental  "  tic  (Cruchet).  As  for  bulbo-medullary  tic,  it 
appears  to  us  to  be  identical  with  spasm  as  we  have 
defined  it,  unless  indeed  it  is  to  be  taken  as  signifying 
a  tic  begotten  of  a  spasm,  in  which  interpretation 
Grasset  and  Brissaud  both  acquiesce. 


TIC  AND   FUNCTION 

"We  must  now  pass  on  to  elaborate  our  conception 
of  tic  as  a  disordered  functional  act. 

The  term  function  is  employed  to  denote  various 
biological  phenomena  differing  widely  in  manifestation 
and  design.  Vegetative  functions  such  as  digestion, 
circulation,  urination,  etc.,  are  regulated  by  a  special 
unstriped  muscle  system,  the  mechanism  of  which 
cannot  be  suspended  by  cortical  interposition ;  hence 
under  no  circumstances  can  its  derangement  bring  a 
tic  into  being. 

Other  functions,  subserved  by  striped  muscles,  come 
within  the  range  of  voluntary  activity.  Some — e.g. 
respiration — are  essential  to  the  maintenance  of  life, 
and  scarcely  to  be  differentiated  from  those  we  have 


THE  PATHOGENY  OF   TIC  69 

called  vegetative.  Others,  such  as  nictitation,  mastica- 
tion, locomotion,  are  no  whit  less  important,  since 
their  cessation,  in  the  absence  of  extraneous  aid,  would 
speedily  have  a  detrimental  effect  on  the  organism. 
They  too  are  in  a  sense  vital. 

Others,  again,  such  as  expectoration,  are  useful, 
though  not  indispensable.  Some  people  labour  under 
the  disadvantage  of  being  unable  to  expectorate,  but 
it  is  not  a  fatal  defect.  The  function  is  not  universal. 

Finally,  let  us  take  once  more  the  case  of  the  child. 

As  he  grows  up  he  passes  by  easy  transitions  from 
the  voluntary  to  the  automatic  stage.  He  is  taught 
to  swim,  and  swimming  soon  rivals  walking  in  the 
unconcern  with  which  the  movements  are  executed ; 
he  learns  to  write,  and  no  less  rapidly  does  the  act 
become  one  of  unconscious  familiarity ;  his  games,  his 
exercises,  the  labour  of  his  hands — be  it  digging  or 
typewriting — all  reach  the  level  of  regular  automatism ; 
in  short,  they  are  functional  acts  as  truly  as  locomotion 
or  even  respiration,  with  the  qualification  of  being 
neither  essential  nor  general. 

Such  examples  serve  to  illustrate  the  comprehen- 
siveness of  the  term  functional,  and  embody  all  the 
intermediate  forms  between  what  is  inherently  vital 
and  what  is  purely  acquired.  When  we  have  to  deal  in 
practice  with  a  case  of  functional  disease,  discrimination 
is  obligatory  from  the  standpoint  of  prognosis.  We 
are  alarmed  at  our  patient's  respiratory  embarrassment, 
not  at  his  impaired  caligraphy. 

A  distinction  has  also  been  drawn  between  functional 
and  professional  affections,  profession  being  conceived 
as  a  function  of  the  individual  in  relation  to  society. 
But  the  latter  term  has  the  drawback  of  being  too 
exclusive.  As  a  matter  of  fact,  scriveners'  palsy  is 
met  with  in  people  who,  so  far  from  being  professional 
writers,  do  not  use  the  pen  much  at  all.  Nor 


70  TICS  AND   THEIR    TREATMENT 

is  it  necessary  to  be  a  professional  pianist  to  develop 
pianists'  cramp.  It  would  be  more  accurate  to  speak  of 
disturbances  in  "  occupation  acts,"  it  being  understood 
that  these  have  by  dint  of  repetition  acquired  the 
automatic  characters  of  true  functional  acts. 

Let  us  consider  for  a  moment  the  salient  features 
and  component  elements  in  our  conception  of  function. 

First  and  foremost  is  repetition.  It  is  an  absolute 
law,  this  of  the  periodicity  of  function,  and  strikingly 
exemplified  in  the  case  of  the  circulation,  digestion, 
urination,  etc.  Regularity  of  rhythm  is  no  less  obvious 
in  the  muscular  activity  of  mastication,  locomotion, 
and  respiration,  and  its  degree  seems  to  be  in  direct 
proportion  to  the  duration  and  vital  importance  of 
the  particular  function. 

The  characters  of  this  rhythm  may  be  influenced 
by  various  extraneous  causes.  A  painful  stimulus 
makes  us  blink  or  quickens  our  respiration.  The  will 
may  intervene,  to  accelerate  or  retard.  The  personal 
factor  accounts  for  individual  differences,  but  for  each 
individual  a  certain  rhj^thm  and  amplitude  of  movement, 
suited  exactly  to  the  end  in  view  and  conforming  to 
the  natural  law  of  least  effort,  may  be  regarded  as 
normal.  It  is  only  in  pathological  cases  that  this  law 
admits  of  exceptions,  and  these  we  shall  now  proceed 
to  investigate. 

Disobedience  to  the  law  in  the  shape  of  exaggera- 
tion or  redundance  of  purposive  movement  indicates 
functional  excess.  For  instance,  the  object  of  the 
function  of  nictitation  is  to  moisten  the  conjunctiva. 
In  its  evolution  the  child's  unmethodical  reaction 
gives  place  to  the  rhythmical  automatism  of  the  adult. 
Perfection  is  the  fruit  of  education. 

But  the  person  whose  impetuous  and  uninterrupted 
blinking  far  exceeds  the  demand  of  the  eye  for  lubrication 


THE  PATHOGENY  OF  TIC  71 

is  plainly  troubled  with  excess,  with  "  hypertrophy  "  of 
function.  Herein  may  consist  a  tic,  and,  in  fact,  a 
large  number  of  tics  are  nothing  more  than  functional 
derangements  of  this  kind. 

The  execution  of  a  functional  act  at  an  inopportune 
moment  constitutes  another  variety  of  functional  dis- 
order. A  smile  with  no  pleasant  thought  to  correspond ; 
a  cry,  a  word,  that  betoken  no  precise  idea  ;  a  gesture 
to  relieve  an  irritation  that  does  not  exist ;  a  chewing 
movement  when  the  mouth  is  empty — all  are  examples 
of  untimely,  inappropriate  functional  acts,  which  merit 
the  name  of  tics  if  in  addition  they  are  anomalous  as 
regards  rhythm,  amplitude,  and  intensity. 

Again,  the  performance  of  function  is  accompanied 
by  antecedent  desire  and  subsequent  satisfaction. 
Authoritative  proof  of  this  law  is  furnished  by  the  case 
of  micturition  and  of  defsecation,  although  momentary 
suspension  of  the  function  of  nictitation  or  of  respiration 
is  also  a  sufficiently  convincing  mode  of  demonstrating 
its  truth.  In  the  case  of  locomotion  and  other  motor 
functions  a  preliminary  feeling  of  need  may  not  be  so 
imperative,  but  it  is  none  the  less  constant. 

Now,  it  has  been  observed  already  that  these 
are  equally  conspicuous  features  in  our  conception 
of  tic.  In  so  far,  then,  as  the  latter  is  preceded  by 
irresistible  impulsion  and  followed  by  inordinate  content, 
it  may  be  considered  a  functional  affection. 

We  cannot,  however,  dispose  of  each  and  every 
tic  as  an  anomaly  of  some  normal  universal  function. 
We  have  already  had  occasion  to  notice  a  large 
number  of  functional  acts  that  are  not  of  general 
distribution,  so-called  professional  movements,  which 
of  course  are  liable  to  derangement.  Such  functional 
disturbances  may  be  styled  professional  cramps,  spasms, 
or  neuroses ;  but  are  they  identical  with  tics  ? 

To  attach  the  majority  of  them  to  the  tics  is,  in 


72  TICS  AND    THEIR    TREATMENT 

our  opinion,  justifiable.  They  are  the  clinical  expression 
of  abnormalities  supervening  in  a  function  that  has 
by  repetition  acquired  the  automatism  of  genuine 
functional  acts :  they  are  germane  to  the  tics.  In 
certain  points,  however,  the  analogy  is  not  absolute. 

Professional  cramps  are  motor  phenomena  dis- 
tinguished by  arrest  of  intended  movement.  Spasm 
signifies  excess  of  motor  reaction,  cramp  denotes  its 
inhibition.  It  cannot,  then,  be  said  that  they  present 
the  characteristic  features  of  spasm  as  we  have  defined 
it:  they  are  akin  rather  to  a  form  of  tonic  tic  of 
which  we  shall  give  instances  later. 

With  this  premise,  we  can  identify  the  professional 
cramp  as  a  functional  anomaly  recognisable  by  defective 
amplitude  and  force  on  the  part  of  the  motor  reaction. 
Its  most  special  character  is  its  appearance  exclusively 
during  the  exercise  of  the  function  of  which  it  forms 
the  anomaly.  Writers'  cramp  manifests  itself  in  the 
act  of  writing,  dancers'  cramp  during  dancing,  and  so 
on.  We  are  ready  to  admit  the  close  affinity  of  pro- 
fessional cramp  to  tic,  with  which  it  has  an  additional 
element  in  common  in  its  occurrence  among  the 
psychically  unstable.  But,  regarded  as  a  tic,  it  is 
unique  in  its  dependence  on  the  casual  exhibition 
of  the  professional  act ;  as  long  as  the  telegraphist  has 
no  occasion  to  transmit  messages,  his  occupation  cramp 
will  not  incommode  him  in  the  least. 

The  great  majority  of  genuine  tics,  on  the  other 
hand,  are  roused  into  activity  by  anything  or  nothing, 
and  this  distinction  is  fundamental. 

With  all  due  recognition,  therefore,  of  the  marked 
resemblances  between  the  two,  we  shall  be  well  advised 
in  not  confounding  them  under  one  designation.  For 
want  of  a  better  word,  we  shall  use  the  phrase  profes- 
sional cramp  to  specify  functional  disturbances  taking 
place  solely  during  the  discharge  of  professional  acts. 


THE   PATHOGENY  OF   TIC  73 

One  other  class  remains  to  be  dealt  with,  consisting 
of  functional  acts  not  merely  superfluous  but  actually 
prejudicial  to  him  who  is  at  once  their  creator  and 
their  slave.  The  idea  that  induced  them  and  the  object 
they  have  in  view  are  alike  irrational. 

An  individual  as  he  moves  his  arm  one  day  becomes 
aware  of  a  cracking  feeling  in  his  shoulder-joint,  and 
from  the  unwonted  nature  of  the  sensation  emanates 
the  notion  that  he  must  have  some  form  of  arthritic 
lesion.  Renewal  of  the  gesture  is  attended  with 
reproduction  of  the  sound.  The  thought  of  a  possible 
injury  develops  and  extends  until  it  is  an  object  of 
constant  preoccupation  and  becomes  a  fixed  idea. 
Under  its  malign  influence  the  movement  is  repeated 
a  hundredfold  and  with  growing  violence  until  it  passes 
into  the  field  of  automatic  action.  It  is  typically 
functional  in  its  repetition,  in  the  association  of  desire 
and  satisfaction;  but  it  originates  in  an  absurd  idea, 
and  is  actuated  by  a  meaningless  motive :  its  range 
is  exaggerated,  its  performance  irresistible,  and  its- 
reiteration  pernicious.  In  fact,  it  is  a  tic. 

"We  may  thus  regard  tic  as  an  obsolete,  anomalous- 
function — a  parasite  function — engendered  by  some 
abnormal  mental  phenomenon,  but  obeying  the  im- 
mutable law  of  action  and  reaction  between  organ  and 
function,  and  therefore  just  as  prone  to  establish  itself 
as  any  motor  act  of  the  physiological  order. 


CHAPTER  IV 

THE    MENTAL    CONDITION    OF    TIC    SUBJECTS 

fTlHE  existence  of  psychical  abnormalities  in  the  sub- 
-L  jects  of  tics  is  no  new  observation.  Charcot l  used 
to  say  that  tic  was  a  psychical  disease  in  a  physical 
guise,  the  direct  offspring  of  mental  imperfection — an 
aspect  of  the  question  which  has  been  emphasised  by 
Brissaud  and  by  ourselves  on  more  than  one  occasion.3 

How  is  the  involuntary  and  irrational  repetition  of 
a  voluntary  and  rational  act  to  be  explained  ?  "Why  is 
inhibition  of  a  confirmed  tic  so  laborious?  It  is  pre- 
cisely because  its  victim  cannot  obviate  the  results 
of  his  own  mental  insufficiency.  Exercise  of  the 
will  can  check  the  convulsive  movement,  but  it  is 
unfortunately  in  will  power  that  the  patient  is  lack- 
ing. He  shows  a  peculiar  turn  of  mind  and  a  certain 
eccentricity  of  behaviour,  indicative  of  a  greater  or 
less  degree  of  instability  (Brissaud).  Noir  writes  in 
much  the  same  strain,  that  careful  examination  will 
readily  demonstrate  the  secondary  nature  of  the  motor 
trouble  ;  behind  it  a  mental  defect  lurks,  which  may 
pass  for  singularity  of  character  merely,  or  childish 
caprice,  but  which  none  the  less  may  be  the  earliest 
manifestation  of  fixed  ideas  and  of  mania. 

It  is  a  matter  of  some  difficulty  to  describe  adequately 
the  features  of  this  mental  condition ;  their  extreme 

1  CHARCOT,  Lefons  du  mardi,  1887-8,  p.  124. 

*  Communication  faite  au  Congres  de  Limoges,  August,  1901  ; 
Soc.  de  neur.  de  Paris,  April  18,  1901 ;  Gazette  des  hdpitaux,  June  20, 
1901,  p.  673;  Progres  medical,  Sept.  7,  1901,  p.  146. 

74 


MENTAL   CONDITION  OF  TIC  SUBJECTS    75 

variability  has  its  counterpart  in  the  diversity  of  the 
motor  phenomena.  In  this  polymorphism  of  psychical 
defect  is  justification  for  the  numbering  of  the  tic 
patient  with  the  vast  crowd  of  degenerates,  and  in- 
deed Magnan1  is  content  to  consider  tic  one  of  the 
multitudinous  signs  of  mental  degeneration.  As  a 
matter  of  fact,  one  does  find  numerous  physical  and 
mental  stigmata  in  those  who  tic,  just  as  one  finds  them 
in  those  who  do  not. 

It  therefore  becomes  desirable  to  specify  in  greater 
detail  the  mental  peculiarities  of  patients  who,  by  reason 
of  their  motor  anomalies,  form  a  distinct  clinical  group 
both  from  the  neuropathological  and  from  the  psychia- 
trical point  of  view.  The  pathogeny  of  these  motor 
troubles  will  thus  be  elucidated  and  valuable  indications 
for  treatment  obtained. 

"Whatever  be  our  theory  of  tic,  whatever  be  the 
shape  the  individual  tic  assumes,  it  is  in  essence  always 
a  perturbation  of  motility,  corresponding  to  a  psychical 
defect.  No  doubt  appearances  are  deceptive,  and  the 
brilliance  of  the  subject's  natural  gifts  may  mask  his 
failings.  His  intelligence  may  be  high,  his  imagination 
fertile,  his  mind  apt,  alert,  and  original,  and  it  may 
require  painstaking  investigation  to  reveal  shortcomings 
none  the  less  real.  This  practice  we  have  scrupulously 
observed  in  all  the  cases  that  have  come  under  our 
notice,  and  we  believe  that  the  information  gleaned 
in  this  way,  coupled  with  the  results  of  previous 
workers,  warrants  the  attempt  at  a  systematic  descrip- 
tion of  the  mental  state  common  to  all  who  tic. 

Charcot2  had  already  remarked  the  presence  of 
certain  signs  or  psychical  stigmata  indicative  of  de- 
generation, or  of  instability,  as  he  preferred  to  say, 
inasmuch  as  the  mental  anomalies  of  these  so-called 

1  MAGNAN,  Recherches  sur  les  centres  nerveux,  2nd  series,  p.  116. 
*  CHARCOT,  Lemons  du  mardi,  October  23,  1888. 


76  TICS  AND   THEIR   TREATMENT 

degenerates  were  not  only  frequently  unobtrusive,  but 
in  a  great  many  cases  associated  with  intellectual 
faculties  of  the  first  order.  His  contention  has  been 
amplified  by  Ballet:1 

The  striking  feature  of  these  "  superior  degenerates  "  or  "  unstables  " 
is  not  the  insufficiency,  but  the  inequality,  of  their  mental  development. 
Their  aptitude  for  art,  literature,  poetry,  less  often  for  science,  is  some- 
times remarkable  ;  they  may  fill  a  prominent  place  in  society ;  many 
are  men  of  talent,  some  even  of  genius  ;  yet  what  surprises  is  the 
embryonic  condition  of  one  or  other  of  their  faculties.  Brilliance  of 
memory  or  of  conversational  gifts  may  be  counteracted  by  absolute 
lack  of  judgment  ;  solidity  of  intellect  may  be  neutralised  by  more  or 
less  complete  absence  of  moral  sense. 

In  the  category  of  "superior  degenerates" — to  use 
Ballet's  terminology — will  be  found  the  vast  majority 
of  sufferers  from  tic,  of  whom  0.  may  serve  for  the 
model.  A  no  less  instructive  example  is  that  of  J. : 

Of  superior  intelligence,  lively  disposition,  and  ingenious  turn  of  mind. 
J.  is  dowered  with  unusual  capabilities  for  assimilation.  Everything  comes 
easy  to  him.  At  school  he  was  one  of  the  foremost  pupils,  and  his  work 
elicited  only  expressions  of  praise.  He  is  both  musical  and  poetical  ;  his 
quickness  and  neatness  of  hand  find  outlet  in  his  passion  for  electricity  and 
photography  ;  for  mathematics  alone  he  has  little  inclination. 

In  a  word,  as  with  physical  imperfection,  so  with 
mental — it  may  consist  either  in  absence,  arrest,  or 
delay,  or  in  overgrowth,  increase,  exaggeration,  and 
these  contrary  processes  may  co-exist  in  the  same 
individual.  Sufficient  stress,  however,  has  not  been 
laid  on  a  practically  constant  feature  in  the  character 
of  the  tiqueur — viz.  his  mental  i/nfantiliam,  evidenced, 
as  was  noted  by  Itard  in  1826,  by  inconsequence  of 
ideas  and  fickleness  of  mind,  reminiscent  of  early 
youth  and  unaltered  with  the  attainment  of  years 
of  discretion.  We  must  remember  that  imperfection 
of  mental  equilibrium  is  normal  in  the  child,  and 
1  BALLET,  Traiti  de  mtdecine,  vol.  vi.  p.  1158. 


MENTAL   CONDITION  OF  TIC  SUBJECTS    77 

that  perfection  comes  with,  adolescence.  In  the  infant 
cortico-spinal  anastomoses  are  awanting,  and  voli- 
tional power  is  dependent  on  their  establishment  and 
development.  At  first,  cortical  intervention  is  in- 
harmonious and  unequal:  the  child  is  vacillating 
and  volatile ;  he  is  a  creature  of  sudden  desire  and 
transient  caprice  ;  he  turns  lightly  from  one  interest 
to  another,  and  is  incapable  of  sustained  effort;  at 
once  timid  and  rash,  artless  and  obstinate,  he  laughs 
or  cries  on  the  least  provocation ;  his  loves  and  his 
hates  are  alike  unbounded. 

These  traits  in  the  child's  character  pertain  equally 
to  the  patient  with  tic,  in  whom  retarded  or  arrested 
development  of  volition,  physical  and  mental  evolution 
otherwise  being  normal,  is  the  principal  cause  of  faulty 
mental  balance.  That  this  view  is  correct  may  be 
inferred  from  a  comparison  of  the  individual  patient 
with  healthy  subjects  of  his  own  age.  The  chief 
•element  in  mental  infantilism  is  maldevelopment  of 
the  will.  While  in  the  child  deficiency  of  what  one 
might  call  mental  ballast  is  usually  atoned  for  by  well- 
conceived  discipline  and  education,  it  is  accentuated 
by  misdirected  teaching.  Now,  it  not  infrequently 
happens  that  the  upbringing  of  the  predisposed  to  tic 
is  not  all  that  might  be  desired,  seeing  that  mental 
defect  on  the  part  of  the  parents  renders  them  unsuit- 
able as  instructors  of  youth.  Parental  indulgence 
or  injustice  is  the  fertile  source  of  ill-bred  or  spoiled 
children,  in  whom,  spite  of  years,  persist  the  mental 
peculiarities  proper  to  childhood.  From  the  ranks  of 
these  spoiled  children  is  recruited  the  company  of  those 
who  tic,  for  tics,  generally  speaking,  are  nothing  more 
than  bad  habits,  which,  in  the  absence  of  all  restrain- 
ing influence,  negligence  and  weakness  on  the  side  of 
the  parents  have  allowed  to  degenerate  into  veritable 
infirmities.  These  the  patients  themselves  are  in- 


78  TICS  AND    THEIR    TREATMENT 

capable  of  inhibiting,  for  whatever  be  their  age,  they 
remain  "  big  children,"  badly  bred  and  capricious, 
and  ignorant  of  any  self-control.  Hence  one  of  the 
first  indications  in  their  treatment  is  to  submit  them 
to  a  firm  psychical  discipline,  calculated  specially  to 
strengthen  their  hold  over  their  voluntary  acts.  Take 
the  following  case: 

J.  is  nineteen  years  old,  intelligent,  educated,  ready  to  graduate 
were  it  not  for  the  interruptions  his  studies  have  undergone,  and  to  all 
appearance  arrived  at  manhood's  estate.  None  the  less  he  presents  to-day 
the  mental  condition  of  nine  years  ago  :  he  is  fickle,  pusillanimous,  naive, 
emotional  ;  he  laughs  at  trifles  and  is  provoked  to  tears  at  the  first 
harsh  word  ;  his  nature  is  restless,  his  mind  inconsequential  ;  he  is  by 
turns  elated  or  depressed  for  the  most  trivial  of  reasons.  Notwithstanding 
his  seventy-one  inches,  he  must  still  be  fed,  dressed,  and  put  to  bed 
by  his  mother  ! 

An  identical  mental  state  obtains  in  infantilism 
properly  so  called,  where  to  arrest  of  mental  develop- 
ment physical  imperfection  is  superadded.  In  cases 
of  infantilism  the  psychical  level  corresponds  more  or 
less  intimately  to  the  somatic  level,  an  observation, 
borne  out  in  the  case  of  J. : 

From  the  morphological  point  of  view  he  shows  one  or  two  stigmata 
of  infantilism  :  his  great  height  need  not  be  held  to  disprove  this,  for 
gigantism  and  retardation  of  sexual  development  are  often  in  association. 
In  spite  of  his  nineteen  years,  J.  has  still  a  eunuch's  voice  and  a  minimum 
of  axillary  and  pubic  hair — in  fact,  one  might  say  that  physically  he 
is  thirteen  years  old,  and  mentally  ten. 

Or  take  Mademoiselle  E..,  aged  twenty-six : 

Her  intellectual  attainments  are  those  of  a  child  of  twelve,  her  age 
when  her  first  tics  made  their  appearance.  Her  artlessness  and  timidity 
are  simply  childish,  and  at  the  same  time  she  lacks  womanly  charm  and 
feminine  ways. 

Or  again: 

Young  thirteen-year-old  M.  has  been  afflicted  with  tics  of  face, 
head,  and  shoulders  for  the  last  three  years.  Though  small,  he  is  well 


MENTAL   CONDITION  OF  TIC  SUBJECTS    79 

enough  built,  and  has  no  obvious  physical  anomaly  except  an  odd 
admixture  of  blonde  and  brown  in  his  hair  and  eyebrows.  His  teeth 
are  bad  and  misplaced,  and  several  of  the  first  dentition  persist.  There 
is  no  sign  of  pubic  or  axillary  growth.  As  a  general  rule  he  is  mild- 
mannered  and  docile  ;  sometimes,  however,  he  is  irritable,  impatient, 
emotional  beyond  his  years.  His  degree  of  intelligence  is  very  fair,  but 
idleness  and  inconstancy  are  prominent  traits  in  his  character.  The 
ease  with  which  he  apprehends  is  counterbalanced  by  the  readiness  with 
which  he  forgets,  while  his  reason  and  judgment  are  those  of  a  child 
of  seven.  The  discordance  between  his  actual  age  and  his  mental  standard 
is  therefore  striking  enough. 

Another  of  our  patients  is  L. : 

Her  intellect  is  quite  up  to  the  average,  but  the  exaggerated  importance 
attached  by  her  parents  to  her  "  nervous  movements "  has  only  served 
to  intensify  her  whims.  Her  eighteen  years  do  not  prevent  her  from 
revealing  signs  of  mental  infantilism  in  every  action  of  her  daily  life,, 
but,  thanks  to  suitable  treatment,  she  has  been  astonishing  her  father  by 
unheard-of  audacities — has  she  not  recently  ventured  to  cross  the  street 
alone,  and  alone  to  go  an  errand  to  a  neighbouring  shop  ? 

X.  has  a  tic  of  the  eyes  and  has  reached  the  age 
of  forty-eight,  yet  he  told  us  he  was  not  so  much 
his  children's  father  as  their  playmate.  At  the  age  of 
fifty-four  0.  could  still  remark  on  his  youthfulness  of 
character.  The  same  is  true  of  S.,  who  has  attained 
his  thirty-eighth  year. 

It  is  as  arduous  a  task  to  define  the  term  "  stability 
of  the  will,"  as  it  is  to  explain  what  is  meant  by  physical 
or  mental  health.  But  as  it  is  not  essential  to  preface 
descriptions  of  disease  with  a  disquisition  on  the  signs 
of  good  health,  so  anomalies  of  voluntary  activity  may 
surely  be  noted  without  a  preliminary  excursus  on 
normal  volition. 

"Will  power  may  deviate  from  the  normal  in  either 
of  two  directions — in  the  direction  of  excess  or  of  in- 
sufficiency. To  both  of  these  two  forms  of  volitional 
disturbance  the  subjects  of  tic  have  become  slaves. 
"Weakness  of  will  is  seen  in  irresoluteness  of  mind, 


So  TICS  AND    THEIR   TREATMENT 

flight  of  ideas,  want  of  perseverance ;  exuberance  of 
will  in  sudden  vagary  or  imperious  caprice.  The  man 
who  tics  has  both  the  debility  and  the  impulsiveness 
of  the  child ;  to  his  impatience  his  incapacity  for 
sustained  effort  acts  as  a  set-off;  he  is  impressionable, 
wavering,  thoughtless,  even  as  he  is  mettlesome  and 
irascible.  He  does  not  know  how  to  will ;  he  wills  too 
much  or  too  little,  too  quickly,  too  restrictedly. 

As  a  single  example  of  volitional  activity,  let  us 
take  the  attention.  Diminution  of  attention  on  the 
part  of  tic  patients  has  been  judiciously  commented 
on  by  Guinon : 

It  is  impossible  for  them  to  address  themselves  to  any  subject  :  they 
skip  unceasingly  from  one  idea  to  another,  and  apply  themselves  with 
zest  to  some  occupation  only  to  forget  it  immediately.  No  further  proof 
of  this  need  be  sought  than  the  inability  of  the  patient,  if  he  be  at 
all  severely  affected,  to  read,  a  proceeding  at  once  intellectual  and 
mechanical,  and  absolutely  familiar  to  most.  Read  the  patient  cannot, 
and  though  the  attempt  to  concentrate  the  attention  diminishes  or 
inhibits  the  tic  at  once,  there  is  no  sequence  in  his  effort  ;  his  eye  jumps 
erratically  from  one  line  to  another,  and  his  many  unavailing  trials 
end  in  his  throwing  the  book  away. 

Excess  of  voluntary  activity  is  disclosed  in  the 
whole  series  of  impulsions. 

The  germ  of  homicidal  or  suicidal  tendencies,  which 
we  have  indicated  in  the  case  of  0.,  is  discoverable  also 
in  one  of  Charcot's  patients.1 

M.  Cbarcot  (to  the  patient) — Tell  us  what  you  said  the  other  day 
about  razors. 

The  Patient — Whenever  I  see  a  razor  or  a  knife,  I  begin  to  thrill 
and  feel  afraid.  I  imagine  I  am  going  to  kill  some  one,  or  that  some  one 
is  going  to  kill  me.  I  have  the  same  sensation  when  I  see  a  gun, 
or  even  if  the  notion  of  a  gun  comes  to  my  mind.  The  mere  thought 
of  it  agonises  me.  The  fancy  of  murdering  some  one  strikes  me,  and 
up  to  a  certain  point  I  am  envious  of  fulfilling  the  desire.  Often  I 
am  conscious  of  an  irresistible  longing  to  fight  somebody,  and  I  am 

1  CHARCOT,  Lefons  du  mardi,  October  23,  1889. 


MENTAL   CONDITION  OF  TIC  SUBJECTS    81 

frequently  impelled  to  it   by  the  sight  of  a  cabman.     Why  a  cabman 
more  than  any  one  else,  I  have  not  the  remotest  idea. 

"We  have  already  touched  on  the  close  affinity  between 
an  act  and  the  idea  of  the  act,  and  we  have  emphasised 
the  absence  of  any  appreciable  interval  between  the 
idea  and  its  execution,  unless  the  brake  of  volitional 
interference  be  put  on  at  the  proper  moment.  It  is  in 
these  circumstances  that  the  feeble  of  will  betray  their 
debility  ;  the  inadequateness  or  inopportuneness  of  their 
will's  activity  allows  the  performance  of  the  act  they 
would  fain  repress. 

A  no  less  characteristic  feature  of  the  subject  of 
tic  is  his  impatience. 

J.  bolts  his  food  without  waiting  to  masticate  it,  and  the  instant 
his  plate  is  empty  jumps  up  from  the  table  to  walk  about  the  house. 
He  returns  for  the  next  course,  which  he  swallows  as  precipitately ; 
delay  makes  him  impatient,  and  all  are  forced  to  rush  as  he  does. 
Meal  time  for  the  whole  family  has  become  a  perfect  punishment. 
Alarmed  enough  already  at  his  tics,  the  parents  are  terror-stricken  by  the 
tyrannical  caprices  of  this  big  baby,  who  outvies  the  worst  of  spoilt 
children  in  his  behaviour. 

Mental  instability  is  not  uncommonly  associated  with 
a  general  restlessness  and  fidgetiness  during  intervals 
of  respite  from  the  actual  tics.  The  patient  experiences 
a  singular  difficulty  in  maintaining  repose.  Every 
minute  he  is  moving  his  finger,  his  foot,  his  arm,  his 
head.  He  passes  his  hand  over  his  forehead,  runs  his 
fingers  through  his  hair,  rubs  his  eyes  or  his  lips, 
ruffles  his  clothes,  plays  with  his  handkerchief  or  with 
anything  within  reach,  crosses  and  uncrosses  his  legs,  etc. 
None  of  these  gestures  can  properly  be  considered  a  tic, 
for,  however  frequent  be  its  repetition,  it  is  neither  in- 
evitable nor  invariable.  If  they  are  superfluous  and 
out  of  place,  the  absence  of  exaggeration  or  absurdity 
negatives  their  classification  as  choreic.  They  are  a 

6 


82  TICS  AND    THEIR    TREATMENT 

sign  not  so  much  of  motor  hyperactivity  as  of  volitional 
inactivity.     They  are  tics  in  embryo. 

The  patient's  emotions  are  similarly  ill  balanced. 
Any  rearrangement  in  his  habits  he  finds  disconcerting ; 
he  is  upset  by  an  unexpected  word,  a  deed,  a  look ; 
his  timidity  and  sensitiveness  are  extreme — fertile  soil 
for  the  development  of  tics. 

So,  too,  with  his  affections,  his  likes  and  dislikes, 
his  friendships  and  enmities — there  is  commonly  a  dis- 
proportion about  them  that  betokens  mental  deficiency. 
At  one  time  it  is  fear  or  repulsion  that  actuates  him ;  at 
another  it  is  an  unnatural  tenderness,  a  sort  of  philia, 
if  the  term  may  be  allowed. 

Anomalies  such  as  these,  however,  are  met  with  in 
all  the  mentally  unstable,  and  do  not  present  any 
special  feature  when  they  occur  in  those  who  tic. 

An  acquaintance  with  the  mental  state  of  our 
patients  enables  us  to  understand  the  mode  their  tic 
adopts.  As  one  thinks,  so  does  one  tic.  To  the 
transiency  and  mutability  of  the  child's  ideas  correspond 
what  are  known  as  variable  tics,  which  rarely  have 
a  definite  localisation,  and  become  fixed  only  when 
certain  ideas  become  preponderant.  The  existence  of 
a  solitary  tic,  however,  is  not  at  variance  with  that 
disposition  we  have  qualified  as  infantile,  for  mental 
infantilism  is  the  original  stock ;  on  it,  as  a  matter  of 
fact,  may  be  grafted  further  mental  disorders  in  the 
shape  of  fixed  ideas,  phobias,  or  obsessions. 

Should  a  fixed  idea  entail  a  motor  reaction,  it  may 
give  rise  to  a  tic  as  ineradicable  as  the  idea  itself,  and  a 
series  of  fixed  ideas  may  be  accompanied  by  a  succession 
of  corresponding  tics. 

The  frequency  with  which  obsessions,  or  at  least  a 
proclivity  for  them,  and  tics  are  associated,  cannot  be  a 
simple  coincidence.  Without  defining  the  word  obses- 
sion, let  us  be  content  to  recall  the  excellent  classification 


MENTAL   CONDITION  OF  TIC  SUBJECTS    83 

given  by  Regis,  according  to  whom  they  mark  a  flaw 
in  voluntary  power,  either  of  inhibition  or  of  action. 
On  the  one  hand  we  have  impulsive  obsessions,  subdivided 
into  obsessions  of  indecision,  such  as  ordinary  folie  du 
doute ;  of  fear,  such  as  agoraphobia ;  of  propensity, 
such  as  those  of  suicide  or  homicide.  On  the  other 
we  find  the  aboulic  obsessions,  such  as  inability  to 
stand  up  (ananastasia),  or  to  climb  up  (ananabasia), 
or  the  astasia-abasia  of  Seglas,  or  the  akathisia  of 
Haskowec.  Perhaps  we  ought  also  to  place  here 
sensory  obsessions  in  the  shape  of  topoalgia,  and  even 
hallucinatory  affections. 

In  all  these  varieties  of  obsession  increase  or 
diminution  of  volitional  activity  is  undeniable.  But 
this  alteration  in  the  function  of  the  will  is  no  less 
distinctive  of  tic,  and  if  we  compare  the  psychical 
stigmata  of  obsessional  patients — the  asymmetry  of 
their  mental  development,  their  intellectual  inequalities 
and  lack  of  harmony,  their  alternating  excitability  and 
depression,  their  unconventionalities,  eccentricities,  and 
imaginativeness,  their  timidity,  whimsicalness,  sensi- 
tiveness, and  all  the  other  indications  of  a  psychopathic 
constitution — if  these  are  compared  with  the  mental 
equipment  of  the  sufferer  from  tic,  we  cannot  but  notice 
intimate  analogies  between  the  two,  analogies  corro- 
borated by  a  glance  at  their  symptomatology. 

An  obsession  may  be  of  idiopathic  origin,  or  it  may 
be  causally  connected  with  some  particular  incident, 
sensation,  or  emotion.  A  conflagration  may  determine 
fear  of  fire,  or  a  carriage  accident  amaxophobia.  Further, 
the  o  bsession  is  irresistible,  as  is  the  tic :  opposition  en- 
dures but  for  a  moment,  and  is  therefore  vain.  Nor  is 
the  inhibitory  value  of  attention  or  distraction  any  less 
ephemeral.  This  feature  of  tic  was  noted  as  long  ago 
as  1850  by  Roth,  who  held  its  motor  manifestations  to 
be  phenomena  of  "irresistible  musculation." 


84  TICS  AND   THEIR   TREATMENT 

Consciousness  is  maintained  in  its  integrity  both 
before  and  after,  but  not  during,  an  obsessional  attack, 
and  this  is  equally  true  of  tic,  as  are  the  preliminary 
discomfort  and  subsequent  satisfaction  that  attend  the 
obsession.  Noir  makes  the  appropriate  remark  that 
idiots  affected  with  krouomania,  in  whom  sensory 
disturbance  is  awanting,  so  far  from  suffering  pain 
through  sundry  self-inflicted  blows  and  mutilations, 
seem,  on  the  contrary,  to  be  thus  afforded  a  certain 
feeling  of  relief,  if  not  of  actual  relish. 

Whenever  Lam.,  who  exhibits  incessant  balancing  and  rotatory  move- 
ments of  the  head,  is  seated  in  proximity  to  a  wall,  he  knocks  his  head 
sideways  against  it  until  a  bruise  results,  and  appears  to  find  therein  a 
source  of  genuine  satisfaction.1 

If,  then,  an  obsession  provokes  a  motor  reaction  at 
all,  it  may  originate  a  tic,  and,  in  the  case  of  tonic 
tics,  this  is  a  very  common  mode  of  derivation,  as  one 
may  well  understand  how  an  obsession  may  occasion 
an  attitude. 

G-rasset  cites  the  example  of  a  young  girl  who  would 
never  lean  backwards  in  a  railway  carriage  or  on  any 
chair  or  bench,  preferring  to  sit  bolt  upright  on  the 
edge.  In  this  instance  the  adoption  of  a  stereotyped 
attitude  was  directly  attributable  to  an  obsession. 

Another  example  of  an  attitude  tic  is  furnished  by 
the  case  of  young  J. : 

Standing  or  seated,  he  always  has  his  half-flexed  left  arm  firmly 
pressed  against  the  body  in  the  position  assumed  by  hemiplegics.  Its 
pose  and  inertia  and  the  awkwardness  of  its  movements  unite  to  suggest 
some  real  affection,  the  existence  of  which  the  constant  use  of  the  right 
arm  and  the  elaboration  by  the  patient  of  intricate  devices  to  obviate 
disturbing  the  other  tend  to  substantiate.  Nevertheless,  the  impotence 
is  entirely  imaginary.  To  order  he  can  execute  any  movement  of  the 
left  arm  with  energy  and  accuracy  ;  his  left  hand  will  button  or  un- 
button his  clothes,  lace  his  boot,  handle  a  knife,  and  even  hold  a  pen 
and  write. 

1  NOIR,  Thise  de  Paris,  obs.  xviii.  p.  40. 


MENTAL   CONDITION  OF  TIC  SUBJECTS    85 

It  seems  that  the  position  of  the  arm  was  chosen  deliberately  to 
alleviate  a  supposed  pain  in  the  shoulder,  and  unceasing  resort  to 
this  subterfuge  of  his  own  inventing,  which  he  considered  a  sovereign 
remedy,  ended  in  its  voluntary  adoption  being  succeeded  by  its  automatic 
reproduction. 

The  assumption  of  this  position  for  his  arm  was  at  first  attended 
with  satisfactory  results,  but,  as  might  have  been  foreseen,  its  inhibitory 
value  decreased  gradually,  so  he  had  recourse  to  other  means.  It  was 
then  that  the  right  hand  was  made  to  grip  the  left  and  press  it  more 
energetically  than  ever  against  the  epigastrium.  In  this  complex  attitude 
both  arms  simultaneously  participated,  but  again  its  efficacy  was  purely 
transitory.  Evidently  dissatisfied  with  his  methods  of  immobilisation, 
and  convinced  that  experimentation  would  end  in  the  discovery  of  the 
desired  arrangement,  J.  proceeded  to  employ  the  right  hand  in  impress- 
ing every  variety  of  passive  movement  on  the  left  hand,  wrist,  forearm, 
and  upper  arm,  and  soon  there  was  no  checking  these  gymnastic 
exercises.  He  would  suddenly  grasp  the  wrist  and  pull  and  screw 
it,  while  the  left  shoulder  and  elbow  resisted  nobly  ;  or  he  would 
bend,  or  unbend,  or  twist  his  fingers,  or  seize  the  arm  below  the  axilla 
and  knead  it  or  rub  it,  forcing  it  against  or  away  from  the  thorax  ; 
he  would  pound  the  muscles  and  pinch  the  tendons,  sometimes  in  a 
brutal  fashion  ;  in  short,  the  situation  degenerated  into  nothing  more 
nor  less  than  a  pitched  battle  between  the  left  arm  and  the  right 
hand,  in  which  the  latter  endeavoured  by  a  thousand  tricks  to  bring 
the  former  into  subjection.  Victory  rested  always  with  the  affected 
arm. 

Each  time  that  this  absurd  combat  recommenced,  the  patient  ex- 
perienced a  sensation  of  relief;  resignation  to  the  imperious  motor 
obsession  was  even  followed  by  a  sense  of  well-being.  On  the  other 
hand,  resistance  was  accompanied  by  actual  anguish — he  would  fidget 
desperately  in  his  chair,  cross  and  uncross  his  legs,  sigh,  grimace,  rub 
his  eyes,  bite  his  lips  and  nails,  twist  his  mouth  about,  pull  at  his  hair 
or  his  moustache,  he  would  look  anxious  or  alarmed,  would  become  by 
turns  red  or  pale,  and  beads  of  perspiration  would  gather  on  his  face.  At 
length  he  would  be  compelled  to  yield,  and  the  bloodless  battle  of  his 
upper  limbs  would  close  more  furiously  than  ever. 

In  this  case  the  typical  features  of  obsession  are 
excellently  illustrated — its  irresistibility,  as  well  as  the 
concomitant  distress  and  succeeding  content. 

Conversely,  however,  a  tic  may  be  said  to  develop 
into  an  obsession  if  the  exciting  cause  of  the  latter  be 
the  motor  reaction. 


86  TICS  AND    THEIR    TREATMENT 

In  various  psychopathic  conditions  (says  Dupre" '),  especially  where 
the  genito-urinary  apparatus  is  concerned,  this  pathogenic  mechanism  is 
encountered.  Some  source  of  peripheral  irritation  in  bladder,  urethra, 
prostate,  etc.,  provokes  cortical  reaction,  and  a  reflex  arc  is  established 
with  centrifugal  manifestations  in  the  guise  of  motor  phenomena,  which 
in  their  turn  originate  all  sorts  of  fixed  ideas,  impulsions,  and  obsessions, 
forming  an  integral  part  of  the  syndrome. 

There  is  frequently  no  direct  or  obvious  connection 
between  a  patient's  obsession  or  obsessions  and  his  tics. 
The  former  may  consist,  both  in  children  and  in  adults, 
in  extraordinary  scrupulousness,  perpetual  fear  of  doing 
•wrong,  absolute  lack  of  self-confidence,  sometimes  simply 
in  excessive  timidity,  exaggerated  daintiness,  or  inter- 
minable hesitation.  We  have  often  seen  youthful  sub- 
jects betray  in  their  disposition  weak  elements  such  as 
the  above,  which  at  a  later  stage  have  proved  the 
starting-point  for  more  definite  obsessions.  Their  intel- 
ligence and  capacity  for  work  earn  the  approbation  of 
their  teacher,  yet  they  are  for  ever  dissatisfied,  haunted 
by  the  dread  of  having  overlooked  some  iota  in  their 
task ;  they  dare  not  affirm  that  they  know  their  lessons, 
they  stammer  over  their  answers,  mistrust  their  memory, 
make  no  promises  and  take  no  pledges,  and  thus  bear 
witness  to  an  absence  of  confidence  in  themselves  which 
affects  them  profoundly,  for  they  are  well  enough  aware 
of  its  consequences. 

An  admirable  instance  of  this  is  furnished  by  the 
case  of  young  F.,  or  by  little  G.,  ten  years  old,  who 
suffers  from  a  facial  tic,  and  constantly  hesitates  when 
asked  to  give  a  measurement,  an  hour,  a  date,  a  figure, 
solely  by  reason  of  a  conscientious  fear  of  not  being 
absolutely  accurate  in  his  reply. 

In  children  the  emotional  excitement  of  their  first 
Communion  often  favours  the  development  of  religious 
scruples.  By  a  sort  of  metastasis,  diminution  of  the 

1  DUPRE,  Soc.  de  neur.  de  Paris,  April  18,  1901. 


MENTAL   CONDITION  OF   TIC  SUBJECTS    87 

convulsive  movements  goes  pari  passu  with  aggravation 
of  the  mental  phenomena,  until  such  a  time  as  the 
devotional  exercises  are  done  with,  when  there  is  a 
return  to  the  previous  state. 

Arithmomania  betokens  an  analogous  turn  of  mind. 
Certain  patients  are  compelled  to  count  up  to  some 
number  before  performing  any  act.  One  cannot  rise 
from  his  seat  without  counting  one,  two,  three,  four,  five, 
seven,  leaving  out  six  since  it  is  disagreeable  to  him. 
Another  must  repeat  the  same  movement  two,  three,  ten 
times,  must  turn  the  door-handle  ten  times  ere  opening 
it,  must  take  five  steps  in  a  circle  before  beginning  to 
walk  (G-uinon).  A  patient  of  Charcot's  used  insanely 
to  count  one,  two,  three,  four,  used  to  look  under  his 
bed  three  or  four  times,  and  could  not  lie  down  until 
assured  that  his  door  was  bolted.  A  further  example 
is  reported  by  Dubois: 

A  young  woman  twenty  years  of  age  first  began  to  suffer  from  con- 
vulsive tics  five  years  ago.  Without  any  warning  she  used  to  bend  down 
as  if  with  the  intention  of  picking  up  something,  but  she  had  to  touch 
the  ground  with  the  back  of  her  hand,  else  the  performance  was 
repeated.  Twenty  or  thirty  times  a  day  this  act  was  gone  through  ;  in 
the  intervals  she  kept  turning  her  head  to  the  right,  looking  up  at  the 
curtains  in  a  corner  of  the  window,  and  at  the  same  time  making  a  low 
clucking  sound  that  attracted  the  attention  of  those  in  the  room.  For 
nine  or  ten  years  these  two  tics  have  prevailed,  and  have  been  accompanied 
with  certain  obsessions,  such  as  the  impulse  to  count  up  to  three,  to  regard 
any  person  or  object  three  times,  etc.  With  the  generalisation  of  the 
convulsive  movements  various  phobias  have  made  their  appearance — 
viz.  fear  of  horned  animals,  of  earthworms,  of  cats,  of  blight,  etc. 

Onomatomania  is  another  form  of  obsession  which 
may  be  mentioned,  exemplified  by  the  dread  of  uttering 
some  forbidden  word,  or  by  the  impulse  to  intercalate 
some  other.  The  term  folie  du  pourquoi  has  been 
applied  to  the  irresistible  habit  of  some  to  unearth  an 
explanation  for  the  most  commonplace  of  facts :  "  Why 
has  this  coat  six  buttons  ?  "  "  Why  is  so-and-so  blonde  ?  " 


88  TICS  AND    THEIR    TREATMENT 

"Why  is  Paris  on  the  Seine?"  etc.  This  mode  of 
obsession  is  frequent  among  those  who  tic,  and  is 
curiously  reminiscent  of  a  familiar  trait  in  the  character 
of  children,  thereby  supporting  our  contention  of  the 
mental  infantilism  of  all  affected  with  tics. 

Prominent  among  the  mental  anomalies  of  the 
subjects  of  tic  are  found  different  sorts  of  phobia :  fear 
of  death  or  of  sickness,  of  water,  knives,  firearms — 
topophobia,  agoraphobia,  claustrophobia,  etc. 

The  following  most  instructive  case  has  been 
observed  by  one  of  us  over  a  period  of  several 
months : 

S.'s  earliest  attack  of  torticollis,  of  two  or  three  days*  duration  merely, 
occurred  when  he  was  fifteen  years  old,  and  was  attributed  by  his  mother — 
whose  mental  peculiarities,  in  especial  her  fear  of  draughts,  are  no  less 
salient  than  those  of  her  son — to  a  chill  occasioned  by  a  flake  of  snow 
falling  on  his  neck.  S.  is  so  blindly  submissive  that  he  accepts  this 
pathogeny  without  reserve.  Five  years  ago  a  second  torticollis  supervened, 
which  still  persists  to-day,  and  of  which  his  explanation  is  that  he  was 
obliged,  when  standing  at  a  desk,  to  turn  his  head  constantly  to  the  left 
for  two  hours  at  a  time  in  order  to  see  the  figures  that  he  had  to  copy,  and 
was  forced,  after  the  elapse  of  some  months,  to  relinquish  his  work  owing 
to  pain  in  the  occipital  region  and  neck.  From  that  moment  dates  the 
rotation  of  his  head  to  the  left. 

At  the  present  time  his  head  is  turned  to  the  left  to  the  maximum 
extent,  the  homolateral  shoulder  is  elevated  somewhat,  and  the  trunk 
itself  inclines  a  little  in  the  same  direction.  The  permanent  nature  of 
this  attitude  necessitates  his  rotating  through  a  quarter  of  a  circle  on  his 
own  axis  if  he  wishes  to  look  to  the  right.  On  the  latter  side  the 
sternomastoid  stands  out  very  prominently,  and  effectually  prevents  his 
bringing  the  head  round  ;  nevertheless  he  is  greatly  apprehensive  of  this 
happening,  and  as  he  walks  along  a  pavement  with  houses  on  his  right  he 
keeps  edging  away  from  them,  since  he  is  afraid  of  knocking  himself 
against  them.  By  a  curious  inversion,  common  enough  in  this  class  of 
phobia,  he  feels  himself  impelled  to  approach,  with  the  result  that  he 
cannons  against  the  wall  on  his  right  as  he  proceeds. 

Contrary  to  the  habit  some  patients  with  mental  torticollis  have  of 
endeavouring  to  ameliorate  the  vicious  position  by  the  aid  of  high 
starched  collars,  S.  has  progressively  reduced  the  height  of  his  until  he  has 
finished  by  discarding  them  altogether.  As  a  matter  of  fact,  it  is  the 
"swelling"  in  the  neck  caused  by  the  right  sternomastoid  that  is  at  the 


MENTAL   CONDITION  OF  TIC  SUBJECTS    89 

root  of  his  nervousness,  for  he  is  convinced  that  it  preceded  the  onset 
of  the  torticollis,  and  he  has  a  mortal  dread  of  aggravating  it  by  com- 
pression. 

Hence  one  may  perhaps  understand  what  line  of  erroneous  reasoning 
has  led  to  the  establishment  of  the  wryneck.  The  fear  of  draughts,  in- 
stilled in  his  youthful  mind  by  his  mother,  had  the  effect  of  driving  him 
to  half-strangle  himself  with  a  tightly  drawn  neckerchief,  to  hinder 
the  inlet  of  air  and  minimise  the  risk  of  catching  cold,  and  when  he 
commenced  to  turn  his  head  to  the  left  at  his  work,  the  pressure  of 
the  band  round  his  neck  was  felt  most  of  all  on  the  contracted  right 
sternomastoid.  A  glance  at  a  mirror  convinced  him  that  the  unusual 
sensation  was  due  to  an  abnormal  muscular  "  swelling,"  whereat  he  was 
vastly  alarmed  ;  he  hastened  to  change  his  collar,  but  all  to  no  purpose. 
By  dint  of  feverish  examination  and  palpation  of  the  muscle,  he  soon 
acquired  the  habit  of  contracting  it  in  season  and  out  of  season,  till  at 
length  an  unmistakable  mental  torticollis  supervened. 

It  sufficed  to  explain  to  S.  the  r61e  played  by  the  sternomastoid  in 
head  rotation,  and  to  demonstrate  the  absurdity  of  his  interpretation 
of  the  so-called  "  swelling "  :  the  gradual  relaxation  of  the  muscle  and 
consequent  diminution  in  the  "  tumour's "  size  not  only  satisfied  him 
of  its  benign  nature,  but  afforded  such  a  sense  of  relief  as  was  quickly 
made  obvious  by  a  notable  improvement  in  his  condition. 

A  singular  tic  of  genuflexion  occurred  in  a  case 
reported  by  Oddo,  of  Marseilles : 

The  dominant  note  in  the  young  girl's  character  is  her  cowardice  j 
she  is  afraid  of  everything.  Every  evening  before  the  return  of  her 
father  she  repeatedly  looks  into  the  corridor  to  see  that  no  one  is  there  ; 
as  soon  as  her  parent  arrives,  she  locks  the  door  behind  him  hurriedly 
to  prevent  any  one  else  appearing  ;  every  now  and  then  in  her  fear  of 
a  footstep  she  listens  at  the  door,  and  it  is  this  gesture,  this  attitude  of 
listening,  that  has  degenerated  into  a  tic  which  no  amount  of  remonstrance 
or  derision  seems  to  affect. 

Phobias  such  as  these  are  associated  with  an  evident 
tendency  to  melancholia  and  hypochondriasis.  The 
majority  of  our  patients  are  ridiculously  preoccupied 
with  the  state  of  their  health;  the  extraordinarily 
introspective  nature  of  their  minds  is  manifest  in  their 
meticulous  observation,  their  laborious  analysis  of  their 
most  trifling  sensations,  the  zeal  with  which  they  devise 


90  TICS  AND   THEIR   TREATMENT 

the  most  complex  explanation  for  their  simplest 
symptom,  usually  for  the  sake  of  making  the  prognosis 
seem  more  grave. 

At  the  other  pole  from  these  silly  fears  and  dislikes 
we  meet  with  various  absurd  predilections  and  meaning- 
less attractions :  one  can  sit  only  on  a  certain  seat, 
sleep  only  in  a  certain  bed ;  another  cannot  enter  a 
room  except  by  a  particular  door;  a  third  will  make 
a  long  detour  to  pass  along  a  certain  street;  in  this 
street  he  will  always  walk  on  the  same  side,  and 
lengthen  or  shorten  his  stride  to  step  always  on  the 
same  flagstones.  We  are  acquainted  with  the  history 
of  a  wretched  commissionaire  who  could  not  go  an 
«rrand  in  Paris  without  starting  from  the  Place  Clichy, 
and  the  interminable  twists  and  turns  on  his  route  can 
be  imagined  when  his  duty  took  him  from  Montrouge 
to  the  Bastille. 

Akin  to  the  conditions  we  have  been  enumerating 
is  an  exaggerated  love  of  order,  somewhat  unexpected 
in  those  whose  mental  disarray  is  often  extreme. 
Some  cannot  sleep  without  previously  arranging  their 
clothes  in  an  unvarying  plan.  One  of  Guinon's  patients 
contrived  to  have  one  half  of  the  objects  in  front  of 
him  to  his  right,  and  the  other  half  to  his  left.  In  the 
case  of  a  little  nine-year-old  hydrocephalic  child  with 
tics  and  echolalia,  Noir l  makes  the  following  remarks  : 

The  fundamental  element  in  the  child's  character  is  an  overweening 
vanity  coupled  with  an  excessive  orderliness.  Her  desire  of  personal  orna- 
ment is  such  that  at  one  time  she  is  lost  in  admiration  of  a  new  dress,  at 
.another,  she  is  decking  herself  out  with  old  pieces  of  tarletan.  When 
going  to  bed  she  folds  her  clothes  in  the  same  exact  order  each  evening. 
Her  self-conceit  makes  her  furiously  jealous  of  the  attention  paid  to 
.any  other  patient  in  her  presence. 

A  similar  mental  state  has  been  observed  by  Noir 
in  other  hydrocephalics. 

1  NOIR,  These  de  Paris,  obs.  lix.  p.  121. 


MENTAL   CONDITION  OF   TIC  SUBJECTS    91 

The  same  tendency  is  revealed  in  an  inane  search 
after  precision  in  the  most  petty  details,  the  natural 
result  in  the  case  of  conversation,  for  instance,  being 
that  its  thread  is  quickly  lost  in  endless  digressions 
and  parentheses  within  parentheses. 

A  score  of  other  mental  peculiarities,  commonly 
described  as  "  manias "  by  the  lay  mind,  are  nothing 
else  than  fixed  or  obsessional  ideas  in  miniature,  as 
Grasset  says,  and  he  narrates  how  for  a  time  he  himself 
used  to  be  irresistibly  forced,  on  entering  a  railway 
carriage,  to  divide  the  figure  representing  the  number 
of  the  carriage  by  the  number  of  the  compartment. 
He  further  cites  the  case  of  an  otherwise  normal 
individual,  who  whenever  one  foot  strikes  on  a  stone 
raised  a  little  above  the  level  of  the  ground,  is  obliged 
to  seek  an  analogous  sensation  for  the  other,  and 
who  cannot  let  one  hand  touch  anything  cold  without 
giving  its  fellow  the  opportunity  of  receiving  an 
identical  impression.  A  common  impulse  is  to  count 
the  windows  in  the  house  one  is  passing,  or  the  bars 
of  the  railings.  Sometimes  it  is  a  "  mania  "  for  setting 
things  straight,  or  for  rubbing  out  marks  in  a  book ; 
but  while  these  and  similar  psychical  accidents  are 
singularly  prone  to  develop  in  the  subjects  of  tic, 
they  are  not  to  be  considered  in  any  way  special  to 
them. 

Hallucinations,  too,  and  sometimes  actual  delusions, 
may  form  a  basis  from  which  springs  a  motor  reaction 
that  passes  into  a  tic. 

If  even  the  most  sane  among  us  (says  Letulle)  are  conscious  of  a 
wellnigh  invincible  propensity  to  repeat  a  particular  movement  or 
expression  or  sequence  of  thought,  we  can  understand  how  the  temptation 
falls  with  overwhelming  force  on  such  as  suffer  from  persistent  hallucinations 
or  fixed  ideas.  Take,  for  instance,  this  woman  who  utters  a  shrill  cry 
and  waves  her  hand  before  her  face  ;  the  regularity  of  her  action  is 
a  sequel  to  the  delusion  that  possesses  her,  for  in  her  imagination  she 
is  chasing  away  the  birds  that  would  pluck  out  her  eyes.  And  when 


92  TICS  AND    THEIR    TREATMENT 

at   a   later   stage   these   visual   hallucinations   are   lost   in   a    progressive 
dementia,  the  gesture  becomes  an  incurable  tic. 

Here  is  another  patient  :  his  habits  of  continually  washing  his  hands, 
of  expectorating  as  he  passes  any  one,  have  their  explanation  in  his  dread 
of  being  poisoned  by  imaginary  foes,  and,  though  subsequent  mental 
disintegration  precludes  the  possibility  of  the  delusion  continuing,  the 
trick  remains  to  the  end  of  life. 

A  case  has  been  put  on  record  by  Wille,1  under  the 
name  of  "  disease  of  impulsive  tics,"  concerning  a  young 
man  twenty-two  years  of  age,  who,  in  addition  to  the 
grave  taint  of  a  psychopathic  heredity,  exhibited  early 
indications  of  irritability  and  a  tendency  to  obsessions. 
Systematised  movements  of  face,  shoulders,  and  arms, 
accompanied  with  coprolalia,  were  not  long  in  appear- 
ing. It  was  noticed  that  the  psychical  symptoms  were 
periodic,  and  that  their  nocturnal  exacerbation  coincided 
with  the  advent  of  hallucinations.  Two  attacks  of  mania 
came  on,  but  a  cure  followed  after  four  years'  time. 

It  may  be  questioned  whether  we  are  not  dealing 
here  with  a  case  of  dementia  praecox,  rather  than  with 
the  true  Gilles  de  la  Tourette's  disease ;  at  any  rate, 
tic  may  be  a  concomitant  of  grievous  mental  affections. 

Another  case  of  still  more  advanced  mental  deteriora- 
tion may  be  quoted  from  Bresler  : 2 

In  this  patient  contractions  of  facial  and  limb  musculature  at  the  age 
of  nine  were  succeeded  by  some  years  of  epileptic  outbreaks  ;  and 
outrageous  conduct  towards  his  mother  and  sister,  coupled  with  acts  of 
wanton  brutality  and  destruction,  at  length  necessitated  his  removal  to- 
an  asylum.  He  suffers  from  convulsive  tic  of  face  and  shoulders,  while 
his  speech  is  drawling  and  syllabic,  and  interrupted  by  guttural  ejaculations 
corresponding  to  the  manifestations  of  his  tic. 

It  is  superfluous  to  dilate  further  on  this  part  of  our 
subject,  and  we  shall  take  another  opportunity  of  deal- 
ing with  the  question  of  tics  in  idiots  and  the  mentally 

1  WILLE,  Monatschr.f.  Psychiat.  it.  NeuroL  1898,  p.  210 ;  1899,  p.  873. 
*  BRESLER,  "  Beitrag  zur  Lehre  von  der  Maladie  des  Tics  convulsifs,'* 
Neurolog.  Centralb.  1896,  p.  965. 


MENTAL  CONDITION  OF  TIC  SUBJECTS    93 

backward.      For  the    present,   the   statements   of    the 
chapter  may  be  summarised  in  a  few  words : 

In  the  mental  condition  of  the  subject  of  tic  there 
may  be  differentiated  two  elements :  the  one  is  funda- 
mental, and  is  sufficiently  described  in  the  phrase  mental 
infantilism;  the  other  is  superadded,  and  consists  of  a 
multiplicity  of  psychical  imperfections  which  reveal,  at 
the  same  time  as  they  exaggerate,  the  inherent  defects 
constituting  the  former,  in  particular  volitional  infirmity. 
By  this  means  a  useful  clinical  distinction  may  be  drawn 
between  various  tics,  according  as  they  take  their  rise 
in  one  or  other  form  of  mental  affection,  and  at  the 
same  time  the  practical  gain  is  considerable,  for  treat- 
ment must  be  directed  both  to  the  physical  and  the 
psychical  aspect  of  the  malady,  and  its  success  in  the 
former  sphere  is  greatly  dependent  on  intelligent  recog- 
nition of  and  acquaintance  with  the  nature  of  the  latter. 

Manias,  obsessions,  phobias,  and  other  accompaniments  of  the  disease 
known  as  tic  (says  Grasset) — those  abnormal  phenomena  that  testify  to  the 
affection  as  the  stigmata  of  hysteria  confirm  that  neurosis — are  nothing  more 
than  psychical  tics  ;  that  is  to  say,  special  types  of  the  disease.  If  their 
occurrence  is  frequent  and  indeed  habitual,  their  absence  in  no  way 
invalidates  the  diagnosis.  They  resemble  coprolalia,  salutations,  etc.,  in 
being  accidental  and  not  essential  symptoms. 

We  are  entirely  at  one  with  Grasset  on  this  last 
point ;  but  if  they  do  occur,  are  they  to  be  denominated 
tics?  We  must  beg  to  be  excused  for  dwelling  with 
such  insistence  on  a  question  of  words,  but  we  are 
assured  that  the  rigorous  limitation  of  the  word  tic  to 
conditions  in  which  it  is  possible  to  recognise  two  in- 
separable and  indispensable  elements,  one  motor  and 
the  other  mental,  cannot  fail  to  simplify  matters.  Other- 
wise, of  course,  we  are  merely  adding  to  the  meaning 
of  a  term  already  interpreted  in  far  too  liberal  a  fashion. 

Abuse  of  language  such  as  this  leads  to  inevitable 
confusion.  Noir,  for  an  instance,  in  whose  excellent 


94  TICS  AND    THEIR    TREATMENT 

thesis  there  is  abundant  evidence  of  painstaking  observa- 
tion and  judicious  discernment,  is  constrained  to  write  : 

Tics  of  idea  are  exemplified  by  fixed  and  obsessional  ideas,  such  as 
folie  du  doute,  misophobia,  arithmomania,  etc.,  and  are  allied  to  motor 
tics  in  that  they  consist  of  isolated  or  complex  psychomotor  reactions, 
which  may,  however,  assume  a  purely  psychical  form.  They  are  mental 
affections  clothed,  in  the  case  of  convulsive  tic,  in  a  motor  garb. 

In  our  opinion,  all  such  formulas  as  "  tic  of  idea," 
"  psychical  tic,"  "  mental  tic,"  "  motor  tic,"  etc.,  ought 
to  be  abolished.  An  obsession  ought  to  be  called  an 
obsession,  and  there  ought  to  be  a  similar  under- 
standing in  the  case  of  phobias  and  fixed  ideas, 
for  each  and  all  may  exist  independently  of  any  motor 
reaction  whatever,  and  therefore  can  never  be  classed 
with  tic.  It  is  only  when  the  obsession  or  the  fixed 
idea  entails  the  automatic  repetition  of  some  motor 
phenomenon  that  a  syndrome  can  be  constituted  to 
which  the  name  of  tic  may  be  applied.  As  a  matter 
of  fact,  a  tic  can  no  more  be  exclusively  mental  than 
exclusively  muscular.  A  mental  condition  that  does 
not  find  expression  in  a  motor  reaction  is  not  a  tic,  and 
to  speak  of  purely  mental  or  purely  motor  tics  is  a  con- 
tradiction in  terms.  Cruchet's  proposed  category  of 
psycho-mental  tics  serves  only  to  aggravate  the  misunder- 
standing, so  long  as  everyday  usage  emphasises  the 
identity  of  the  two  words  "  psychical "  and  "  mental." 

[Tics  are  not  the  private  property  of  the  human 
species.  The  word  appears  to  have  been  first  employed 
in  reference  to  horses,  and  while  little  attention  has 
hitherto  been  paid  to  the  subject  in  veterinary  annals, 
its  methodical  study  has  recently  been  undertaken  by 
Rudler  and  Chomel.1  It  is  remarkable  how  intimate  are 

1  RUDLER  AND  CHOMEL,  "  Tic  de  Tours  chez  le  cheval,"  Rev. 
neur.  1903,  p.  541 ;  "  Analogies  entre  les  tics  de  I6chage  chez  1'homme 
et  chez  le  cheval,"  Soc.  de  neur.  de  Paris,  January  7,  1904 ;  "  Dea 
stigmates  de  la  d6gen6rescence  chez  Tarn'mal,"  Congres  de  Pau,  1904; 
Nouv.  icon,  de  la  Salpftriere,  1904,  p.  471. 


MENTAL   CONDITION  OF   TIC  SUBJECTS    95 

the  analogies  established  by  these  observers  not  merely 
between  the  tics  of  animals  and  of  mankind,  but  also 
between  their  respective  mental  conditions.  Physical 
and  psychical  stigmata  of  degeneration  are  as  obvious 
in  the  horse  that  tics  as  in  the  man  who  tics,  and  it 
is  not  without  interest  to  note  that  the  tics  of  such 
animals  as  have  the  most  rudimentary  psychical  develop- 
ment present  a  close  resemblance  to  those  that  occur 
among  the  least  advanced  of  the  human  race,  among 
idiots  and  imbeciles.] 


CHAPTER  V 

THE   ETIOLOGY   OP   TICS 

THE  circumstances  favouring  development  of  a  tic 
in  soil  already  prepared  by  psychical  predisposition 
are  manifold.  Our  studies  in  the  pathogenesis  of  tic 
have  illustrated  the  significance  of  exciting  causes,  so- 
called.  We  have  seen  how  the  motor  part  of  the  tic  was 
originally  directed  to  some  definite  object,  and  therefore 
provoked  by  some  definite  cause,  and  how  the  eventual 
disappearance  of  this  cause  does  not  justify  the  con- 
clusion that  it  has  never  existed. 

We  shall  be  able  to  quote  numerous  instances  in 
point  when  dealing  with  the  different  localisations 
assumed  by  the  tics ;  what  we  wish  to  remark  here 
is  that  the  initial  cause  is  by  no  means  always  easy 
to  ascertain.  The  subjects  of  whom  we  are  treat- 
ing exhibit  a  vexatious  tendency  to  invent  a  more  or 
less  fantastic  etiology  for  themselves,  and  their 
statements  cannot  be  accepted  without  rigorous  investi- 
gation. Of  any  actual  exciting  cause  they  may  be 
really  ignorant,  or  more  likely  oblivious. 

In  this  connection  an  important  case  is  reported 
by  Pierre  Janet l : 

A  young  man  twenty-five  years  old  was  affected  with  a  facial  tic 
in  the  shape  of  constant  grimaces,  accompanied  by  violent  expirations 
through  one  nostril.  Six  years  of  the  condition  had  neither  enabled 
him  to  determine  its  origin  nor  brought  him  any  relief.  He  presented, 
in  addition,  the  phenomena  of  automatic  writing  and  was  the  subject 

1  JANET,  Neuroses  etidees  fixes,  vol.  i.  p.  397. 
96 


THE  ETIOLOGY  OF   TICS  97 

of  somnambulism,  and  when  in  the  latter  state  explained  that  the  tic 
arose  from  the  effort  to  expel  an  irritating  nasal  obstruction  due  to 
an  epistaxis  six  years  ago. 

Needless  to  say  (adds  Janet),  there  never  had  been  any  obstruction 
in  the  nose  ;  the  truth  was  that  in  the  somnambulistic  state  he  was 
reminded  of  a  subconscious  fixed  idea  of  which  he  was  ordinarily 
unaware. 

Recognition  of  the  causal  factor,  then,  is  not  with- 
out value,  as  otherwise  the  tic's  situation  and  form 
may  rest  inexplicable. 

These  exciting  causes  we  shall  discuss  more  closely 
at  a  subsequent  stage,  confining  our  attention  for  the 
present  to  one  or  two  general  considerations. 

Age. — Tics  may  occur  at  any  period,  except  in 
infancy.  "  Nervous  movements "  appearing  previous 
to  the  age  of  three  or  four  cannot  be  tics,  as  has  been 
made  plain  in  the  chapter  on  pathogeny.  It  is  only 
with  the  development  of  psychical  function — about 
the  age  of  seven  or  eight — that  revelation  of  its  im- 
perfection, if  such  exist,  becomes  possible. 

Initiation  or  exacerbation  of  a  tic  is  very  frequent 
about  the  time  of  puberty,  when  both  physical  and 
mental  evolution  is  peculiarly  apt  to  suffer  interruption. 

Sex. — Sex  is  without  influence  on  the  disease. 

Race. — In  spite  of  the  absence. of  precise  statistics 
on  the  subject,  the  opinion  that  the  tendency  to  tic 
increases  with  the  advance  of  civilisation  is  not,  we 
think,  premature. 

We  have  had  the  curiosity  to  interrogate  several 
travellers  familiar  with  different  savage  tribes  of 
Central  Africa,  who,  although  notified  beforehand  to 
be  on  the  look-out,  declare  they  have  practically  never 
met  with  tic  in  negroes.  These  observations  require 
to  be  confirmed. 

It  may  be  questioned  if  the  level  of  mental  attain- 
ment of  such  primitive  peoples  is  sufficiently  high  to 

7 


98  TICS  AND   THEIR    TREATMENT 

allow  of  the  establishment  of  tics.  Their  occurrence 
in  the  lower  animals  has  been  recorded,  it  is  true ;  but 
with  our  ignorance  of  what  constitutes  an  animal  tic, 
and  until  further  information  is  forthcoming,  it  is 
prudent  not  to  speculate  on  these  matters.  We  must 
be  content  with  the  remark  that  savages  and  animals 
are  less  exposed  than  the  civilised  to  circumstances 
facilitating  the  development  of  mental  instability. 

Trauma,  and  infectious  disease  may  provide  the 
occasion  for  either  the  appearance  or  the  disappearance 
of  a  tic,  but  of  themselves  they  are  incapable  of 
originating  the  affection. 

One  of  Noir's  patients  had  a  brother  similarly 
afflicted,  and  a  sister  in  whom  an  attack  of  bronchitis 
at  the  age  of  five  was  accompanied  by  tics  of  arm  and 
head,  which  recurred  subsequently  in  an  exaggerated 
form  during  smallpox.  On  each  of  two  occasions  on 
which  J.  suffered  from  influenza  his  tics  increased  in 
violence  and  extent ;  while  in  the  case  of  G.  aggrava- 
tion heralded  the  approach  of  measles. 

Young  M.,  on  the  other  hand,  remained  free  of  all 
his  face  and  head  movements  during  the  immobilisa- 
tion of  a  fractured  leg,  with  the  cure  of  which  his 
tics  returned. 

To  disturbance  of  the  reproductive  organs,  in 
particular  to  uterine  disorders  and  even  pregnancy 
(Growers,  Bernhardt),  has  been  ascribed  the  onset  of  tic. 

Of  the  possible  influence  of  climate,  season,  and 
atmospheric  change  in  general,  precise  information 
is  lacking.  Stormy  weather  or  a  falling  barometer 
frequently  exercises  a  depressing  effect  on  the  subjects 
of  tic,  but  this  is  habitual  in  all  neuropathic  individuals. 
Oppenheim  declares  he  has  seen  severe  cases  of 
convulsive  tic  follow  an  earthquake. 

Heredity. — To  this  Charcot  used  to  attach  the 
greatest  importance.  In  every  case  of  tic,  he  main- 


THE   ETIOLOGY  OF   TICS  99 

tained,1  however  trivial,  especially  if  attended  with 
phenomena  such  as  coprolalia,  a  hereditary  element 
is  discernible. 

Similar  heredity  is  of  common  occurrence.  In 
Gintrac's  cases,  two  brothers  had  the  same  facial  tic. 
Blache's  patients  were  three  children  in  the  same 
family.  Delasiauve  observed  identical  tics  in  brother 
and  sister,  and  Piedagnel  in  mother  and  daughter. 
A  father  and  two  sons  of  whom  Letulle  has  given  an 
account  all  suffered  from  a  tic  of  blinking.  The  same 
author  has  seen  two  brothers  with  a  complex  tic  of 
face,  scalp,  arms,  and  diaphragm.  More  recently 
Tissie  has  recorded  a  series  where  a  mother  was  affected 
with  ocular  tic,  while  the  eldest  son  also  had  an  ocular 
tic,  which  eventually  spread  to  the  face  and  was 
associated  with  a  spasmodic  cough  ;  a  younger  son  was 
likewise  the  subject  of  ocular  tic. 

A  case  has  come  under  our  notice  of  a  young  girl 
with  a  head-tossing  tic  which  had  been  preceded  by  a 
variety  of  others  now  imitated  by  her  youngest  sister, 
such  as  sniffing,  screwing  of  the  face,  shaking  of  the 
shoulders,  abrupt  pulling  up  of  the  garters,  etc. 

These  and  similar  instances  undoubtedly  serve  to 
show  the  effect  of  hereditary  predisposition ;  but  the 
element  of  imitation  enters  no  less  into  the  question, 
and  the  elimination  of  its  influence,  owing  to  family 
promiscuousness,  is  peculiarly  arduous.  To  this  point 
we  shall  revert  immediately. 

Dissimilar  heredity,  in  any  of  its  forms,  neuropathic 
or  psychopathic,  is  no  less  frequently  met  with,  and 
emphasises  the  kinship  of  tic  with  almost  all  the 
psychoses  and  neuroses. 

It  is  a  matter  of  common  observation  for  a  liqueur's 
father  to  be  a  neuropath,  his  mother  a  hysteric, 
his  brother  an  epileptic,  or  his  grandfather  a  general 
1  CHARCOT,  Lefons  du  mardi,  December  13,  1887. 


ioo         TICS  AND   THEIR   TREATMENT 

paralytic  or  a  maniac,  while  neurasthenia,  hypochon- 
driasis,  psychasthenia,  etc.,  or  organic  disease  of  the 
nervous  system,  may  occur  among  the  collaterals. 
A  case  has  been  under  our  care  of  a  boy  M.,  who  has 
two  brothers  and  one  sister,  all  in  good  health.  The 
sister  bites  her  nails.  The  mother  is  normal,  but 
excessively  weak  where  her  children  are  concerned. 
The  father  is  neurasthenic,  and  the  grandfather  has 
trigeminal  neuralgia. 

Occasionally  a  family  history  of  syphilis  or  alcoholism 
is  forthcoming.  Sometimes  tic  and  psychical  troubles 
alternate.  Flatau l  quotes  a  case  of  a  mother  with 
impulsions  and  a  son  with  tics,  and  another  of  a 
mother  and  sister  who  tic,  with  a  son  possessed  of 
fixed  ideas. 

In  the  subjects  of  tic  and  in  their  families,  mental 
instability  and  intellectual  superiority  have  repeatedly 
been  conjoined.  To  refer  again  to  the  case  of  young 
J.,  no  particular  deviation  from  the  normal  was 
traceable  on  the  part  of  any  ancestor  or  relative  on  the 
paternal  side,  except  that  the  father  himself  was  un- 
usually emotional  and  a  prey  to  scruples ;  but  the 
mother's  whole  family  were  either  brilliantly  clever 
or  prematurely  broken  down,  succumbing  to  "  strokes  " 
and  paralyses  of  various  kinds. 

Many  figures  celebrated  in  history  had  their  tic. 

At  the  time  of  his  early  appearances  Moliere  was  held  even  in  the 
provinces  to  be  a  comedian  of  a  very  inferior  order,  owing  perhaps 
to  a  hiccough  or  throat  tic  of  his  leaving  a  disagreeable  impression 
of  his  acting  on  those  who  were  not  aware  of  its  existence.1 

Brissaud  recalls  the  curious  picture  of  Peter  the 
Great  handed  down  to  us  by  Saint-Simon 3 : 

1  FLATAU,  Centralb.f.  Nervenheilk.,  August,  1897. 

'  Vie  de  MoUtre^  1705,  pp.  206-7  (quoted  by  Cruchet). 

1  Memoires  de  Saint-Simon,  year  1707,  vol.  xiv.  p.  427  (Hachette, 


THE   ETIOLOGY  OF   TICS  101 

If  he  gave  thought  thereto,  his  mien  became  majestic  and  gracious, 
else  was  it  forbidding,  and  almost  savage,  his  eyes  and  his  face  occasion- 
ally distorted  by  a  momentary  tic  that  rendered  his  expression  wild 
and  terrible. 

Similarly  with  the  Emperor  Napoleon  * : 

His  moments,  or  rather  his  long  hours,  of  work  and  meditation 
were  characterised  by  the  exhibition  of  a  tic  consisting  in  frequent 
and  rapid  elevation  of  the  right  shoulder,  which  those  who  did  not 
know  him  sometimes  interpreted  as  a  sign  of  dissatisfaction  and  dis- 
approval, seeking  uneasily  wherein  they  could  have  failed  to  please 
him. 

Cases  of  tic  in  the  descendants  of  great  men  are  far 
from  rare ;  we  have  met  with  several  instances. 

Among  etiological  factors  of  a  general  description, 
the  role  played  by  imitation  is  all-important,  especially 
in  the  young.  Mimicry  is  strong  in  the  child's  nature, 
and  bad  habits  are  quickly  contracted.  Should  he 
be  tainted  with  nervous  weakness  in  addition,  he  is 
apt  to  tic  on  the  slenderest  pretext,  in  which  case  to 
encounter,  or  still  more  to  be  associated  with,  the 
subject  of  a  tic  would  be  the  direst  of  misfortunes. 

That  such  a  contingency  should  arise  is  not 
essential.  A  novel  gesture  on  the  part  of  any  one 
catches  the  child's  attention,  and  he  forthwith  at- 
tempts its  reproduction,  finding  therein  a  source  of 
complacent  satisfaction.  On  the  morrow  the  move- 
ment is  repeated,  and  again,  till  it  oversteps  the  bounds 
of  habit  and  enters  the  realm  of  tic. 

Cruchet  concedes  this  to  be  a  possible  though  by  no 
means  invariable  mode  of  tic  production,  for  the  reason 
that  the  unconscious,  or,  more  correctly,  subconscious — 
polygonal,  if  you  will — nature  of  imitation  is  un- 
deniable, indeed  self-evident. 

Without  entering  into  too  great  detail,  it  may  not 
be  amiss  to  examine  this  contention. 

1  CONSTANT,   Memoires,  vol.  i.  p.  340. 


102          TICS  AND    THEIR   TREATMENT 

To  imitate,  in  Little's  definition,  is  "  to  seek  to 
reproduce  what  another  is  doing."  How  such  an  act 
is  to  be  accomplished  without  the  co-operation  of  the 
will  we  cannot  conceive.  Its  duration  being  so  brief, 
our  recollection  of  the  conscious  stage  may  be  very 
imperfect,  but  that  is  no  ground  for  denying  its 
reality.  Involuntary  execution  of  a  gesture  to-day 
does  not  exclude  the  possibility  of  its  voluntary  exe- 
cution yesterday.  If  we  find  accurate  reconstitution 
of  the  steps  in  our  own  habitual  mental  processes  im- 
practicable, a  fortiori  ought  we  to  question  the  likeli- 
hood of  our  gaining  full  insight  into  the  mechanism 
of  the  processes  of  others. 

It  is  no  doubt  this  perplexity  which  has  induced 
Cruchet  to  regard  the  simple  convulsive  tic  as  the  sole 
manifestation  of  the  disease.  On  his  own  admission, 
nevertheless,  this  simple  convulsive  tic  is  of  exceptional 
occurrence,  apart  from  children,  in  whom  mental  trouble 
is  conspicuous  by  its  absence. 

But  the  psychical  disorders  of  infancy,  however 
embryonic  they  be,  are  none  the  less  real.  Their  in- 
significance may  hinder  their  recognition,  yet  they 
are  often  the  prelude  to  graver  and  more  definite 
anomalies  in  later  life.  And  if  their  detection  demands 
painstaking  study  and  repeated  interrogation,  fruitless 
results  may  very  well  mean  that  the  investigation  was 
not  sufficiently  thorough. 

Moreover,  the  view  that  regards  imitation  as  a 
prolific  element  in  the  genesis  of  tics  has  met  with 
widespread  acceptance. 

The  onset  of  the  disease  (says  Guinon)  is  sometimes  the  consequence  of 
the  patient's  partiality  for  mimicry.  Contact  with  an  affected  person 
supplies  the  occasion.  His  first  experience  is  a  sort  of  constant 
preoccupation  ;  the  other's  grimace  is  ever  before  his  eyes,  inviting 
imitation  ;  at  length  he  suddenly  yields  to  the  obsession,  and  his  tic  is 
in  the  making. 


THE   ETIOLOGY  OF   TICS  103 

Reference  has  already  been  made  to  a  case  of 
Tissie's,1  where  an  eight-year-old  child  acquired  from 
its  mother  an  ocular  tic,  which  a  second  child  imitated 
in  its  turn.  The  cure  of  the  latter  was  followed  with 
the  cure  of  the  two  others,  by  imitation. 

The  word  "  echokinesia "  was  imagined  by  Charcot 
to  specify  the  inclination  some  people  show  to  copy 
what  they  see  others  doing.  It  has  also  received  the 
names  of  "  mimicism  "  and  "  imitation  neurosis."  To 
quote  Guinon  again : 

The  movements  most  closely  and  most  infallibly  mimicked  are  facial. 
These  the  patient  either  is  driven  actually  to  reproduce,  or  feels  impelled 
to  reproduce,  without  allowing  the  impulse  to  pass  into  action.  Simple  and 
circumscribed  gestures  involving  the  limbs  are  similarly,  if  less  frequently, 
the  object  of  imitation.  Such  tricks  as  rubbing  the  nose  or  cheek  or 
some  other  part,  or  stooping  as  if  to  pick  up  something  on  the  ground, 
may  be  counterfeited  in  their  entirety,  though  at  other  times  the  movement 
is  only  initiated. 

Echokinesia  may  be  considered  a  motor  disturbance 
analogous  and  akin  to  tic,  but  distinguished  by  the  fact 
that  it  occurs  exclusively  during  the  performance,  and 
as  the  reproduction,  of  some  movement  executed  by 
another.  It  is  true,  of  course,  a  genuine  tic  may  be 
a  reminiscence  of  some  gesticulation,  but  it  is  quite 
independent  of  time  and  place. 

A  similar  difference  exists  between  echolalia — the 
habit  of  repeating  another's  sounds  or  words  at  the 
moment  of  their  ejaculation — and  tics  of  phonation 
or  of  language ;  the  latter  are  always  ill-timed  and 
inappropriate,  though  they  may  have  had  their  origin 
in  acts  of  imitation. 

It  has  become  classical  to  draw  a  comparison 
between  these  echokinesic  phenomena  and  the  obser- 
vations of  O'Brien  apropos  of  latah  among  the  Malays. 

1  TISSIE,  "  Tic  oculaire  et  facial,"  Journ.  de  med.  de  Bordeaux, 
July  9  and  16,  1899. 


104         TICS  AND   THEIR   TREATMENT 

A  sailor  on  board  a  boat  will  pick  up  a  piece  of  wood  and  proceed 
to  rock  it  as  if  it  were  a  child,  whereupon  a  latah  standing  alongside 
commences  to  rock  the  infant  he  holds  in  his  arms.  The  sailor  then 
throws  the  piece  of  wood  on  to  the  deck,  and  the  latah  promptly  follows 
suit  with  the  baby  (Guinon). 

This  is  echokinesia  carried  to  an  extreme,  revealing 
a  complete  absence  of  inhibition  from  the  higher 
psychical  functions. 

Prominent  among  influences  calculated  to  facilitate 
the  evolution  of  tics  is  the  patient's  environment,  more 
particularly  where  children  are  concerned. 

The  parents  are  often  disposed  to  be  deplorably 
"fond."  Their  ignorance  or  their  thoughtlessness 
permits  the  installation  of  obnoxious  habits  and  fosters 
their  growth  into  tics.  Any  endeavour  after  suppression 
usually  serves  to  expose  the  inadequacy  of  the  family 
authority  to  exercise  control  and  compel  obedience. 
For  the  watchful  discipline  that  should  curb  all  such 
childish  tricks  and  caprices  is  unfortunately  substituted 
a  disastrous  indulgence  that  only  stimulates  the  de- 
velopment of  these  embryonic  tics.  It  should  not  be 
forgotten,  moreover,  that  the  mental  instability  of 
the  fathers  is  visited  upon  the  children  in  the  guise 
of  a  certain  aptitude  for  psychical  anomalies. 

The  accompanying  case  supplies  conclusive  evidence 
of  the  mischief  wrought  by  weakminded  parents,  and 
of  the  calamitous  results  of  hereditary  predisposition 
and  bad  example  combined. 

S.'s  mother  is  a  lady  of  over  fifty,  who  spends  her  leisure  hours  in 
writing  novels,  and  who  suffers  from  different  varieties  of  phobia.  In  the 
first  place,  she  has  an  absurd  fear  of  cats  and  dogs.  When  she  goes 
out,  a  maid  follows  at  several  yards'  distance  to  prevent  the  approach  of  any 
dog  from  the  rear  ;  and  if  she  is  driving,  the  same  precautions  are  observed. 

Her  dread  of  chest  complaints  is  equally  extravagant.  A  cold  is  her 
bugbear,  a  draught  her  bite  noire.  In  the  intervals  of  her  literary  labour 
she  occupies  herself  with  seeing  that  all  doors  and  windows  are  properly 
shut.  The  room  temperature  is  maintained  at  68°  F.  at  least. 


THE  ETIOLOGY  OF  TICS  105 

Since  her  husband's  death  her  devotion  to  her  son's  education  has  been 
fatal  to  his  best  interests.  Her  unfailing  solicitude  for  his  health,  'her 
constant  terror  of  accident  and  illness,  have  reduced  volitional  effort  in 
him  to  a  minimum,  and  under  this  regime  of  tyrannical  affection  he  has- 
been  as  delicately  nurtured  as  a  young  girl.  Even  at  the  age  of  thirty  he 
must  be  indoors  at  night  by  ten  o'clock,  and  a  few  minutes'  delay  will 
bring  his  mother  to  a  state  bordering  on  frenzy,  and  end  in  the  dispatch 
of  some  one  to  seek  him  ;  whence  all  sorts  of  domestic  discussions,  and 
quarrels,  and  "  scenes,"  with  tears  and  mutual  recrimination. 

Little  wonder  then,  with  such  an  example,  that,  in  spite  of  his  own 
robust  health,  S.  evinces  the  same  senseless  fear  of  chills  and  colds  and 
currents  of  air,  and  tries  the  doors  and  windows  so  incessantly  and  so 
violently  withal  that  they  have  to  be  repaired  almost  every  month.  In 
his  own  room  they  have  been  doubled  and  padded.  His  anxiety  to  avoid 
catching  cold  actually  leads  him  to  weigh  the  samples  of  cloth  submitted 
to  him,  to  ensure  that  his  next  suit  of  clothes  will  be  of  the  same  weight 
as  his  last. 

With  all  this  excess  of  tenderness,  S.'s  mother  does  not  always  err 
on  the  side  of  leniency.  On  the  contrary,  punishment  is  apportioned  for 
the  most  trivial  fault,  although  it  is  only  necessary  on  S.'s  part  to- 
simulate  illness  for  his  mother  at  once  to  yield  to  his  most  ridiculous 
caprice. 

S.  suffers  from  a  rotatory  tic  of  the  head,  which  he  attributes  to  a 
blow  on  the  neck  once  administered  by  his  mother  by  way  of  chastisement  j 
but  it  may  very  well  be  questioned  whether  the  torticollis  was  not  rather 
a  clever  imposition  intended  to  soften  the  mother's  heart  and  bring  about 
her  repudiation  of  corporal  punishment. 

The  case  of  J.  is  no  less  instructive,  since  he 
came  of  a  family  of  veritable  syphilophobes  whose 
extraordinary  frailties  and  sentimentalities  contributed 
not  a  little  to  the  progress  of  his  disease. 

A  glimpse  into  the  domestic  life  of  L.  is  equally 
illuminating. 

L.  is  an  only  child,  who  from  infancy  has  usurped  her  parents' 
attention.  Their  uneasiness  lest  her  "nervous  movements "  should  prove 
detrimental  to  her  general  health  is  the  explanation  of  her  highly  irregular 
attendance  at  school  and  of  repeated  holidaying.  She  may  not  go  out 
alone,  as  her  "  incantations "  are  liable  to  arrest  her  in  the  middle  of 
the  street  ;  at  the  same  time  lack  of  control  over  her  legs  may  endanger 
her  safety,  and  erratic  arm  gestures  render  the  aid  of  a  stick  or  umbrella 
useless. 


io6          TICS  AND    THEIR    TREATMENT 

To  add  to  her  misfortunes,  her  head  has  now  begun  to  rotate  to  the 
right.  She  used  four  times  a  day  to  cross  the  narrow  and  little  frequented 
road  that  separated  her  father's  house  from  her  place  of  employment ;  but 
since  her  last  accident  she  has  remained  strictly  within  doors,  trifling  away 
the  time  in  a  chair,  and  finding  in  the  petty  life  of  a  side-street  all  that  she 
wants  to  attract  her  gaze  or  arouse  her  interest. 

In  this  microcosm  her  father  has  been  reduced  to  the  position  of  a 
slave.  He  anticipates  her  slightest  want  and  indulges  her  most  fanciful 
whim  ;  his  commiseration  for  her  woes  is  only  equalled  by  his  unselfishness 
in  foregoing  his  own  pleasure  and  his  ingenuity  in  vindicating  her  weak- 
nesses. In  short,  his  ready  acceptance  of  his  daughter's  instability  argues 
a  lack  of  mental  balance  on  his  own  part. 

Brain  fatigue  is  another  element  in  the  formation 
of  tics  whose  influence  ought  not  to  be  underestimated. 
In  the  case  of  young  D.,  nineteen  years  old,  a  cluck- 
ing tic  supervened  during  the  period  of  preparation 
for  an  examination,  to  disappear  at  its  close. 

No  less  fruitful  are  anguish,  anxiety,  worry,  dis- 
appointment, as  will  freely  be  conceded.  Any  prolonged 
concentration  of  the  attention  on  a  particular  act  or 
a  particular  idea  presupposes  a  concomitant  weakening 
of  inhibitory  power  over  other  acts  and  ideas,  which 
then  become  corrupt  and  inopportune,  are  incapable 
of  further  repression,  and  blossom  into  tics. 

Indolence,  too — the  mother  of  all  the  vices,  according 
to  the  adage — favours  the  outbreak  of  tics,  and  ac- 
celerates their  growth.  The  idle  patient's  thoughts  are 
all  for  his  tic ;  its  perfecting  taxes  his  inventiveness. 

Mention  may  be  made  in  passing  of  the  effect  of 
"professional  movements"  in  predisposing  to  the 
subsequent  apparition  of  a  tic  in  the  muscles  concerned. 
We  have  already  alluded  to  the  relation  between  tics 
and  certain  cramps  or  occupation  neuroses,  and  we  shall 
refer  to  the  topic  again  at  a  later  stage. 

It  would  appear  that  even  the  memory  of  a  familiar 
gesture  sometimes  suffices  to  initiate  the  condition: 
witness  Grasset's  case  of  post-professional  colporteur 


THE  ETIOLOGY  OF   TICS  107 

tic,  where  the  subject  reproduced  the  movement  of 
swinging  a  bag  over  his  shoulder,  a  souvenir  of  his 
former  avocation.1 

A.  final  example,  none  the  less  instructive  though  it 
occur  in  lay  literature,  may  be  cited  from  Alfred  de 
Yigny  2 : 

With  a  child's  delight  the  worthy  battalion  commander  gravely 
made  ready  to  speak.  He  readjusted  his  polished  shako  on  his  head,  and 
gave  that  twitch  of  the  shoulder  appreciated  only  by  such  as  have  served 
in  the  infantry — that  twitch  which  is  meant  to  raise  the  knapsack  and 
momentarily  to  lighten  its  load  ;  it  is  a  trick  of  the  soldier's  which  with 
his  elevation  to  officer's  rank  becomes  a  tic.  Another  sip  of  wine  followed 
this  convulsive  gesture,  a  kick  of  encouragement  in  the  little  donkey's 
stomach,  and  he  began.  .  .  . 

The  description  could  not  have  been  more  accurate. 
The  passage  from  the  voluntary  to  the  involuntary — 
the  kick  too  may  have  been  a  tic — and  the  obvious 
infantile  traits  in  the  old  gentleman's  character,  make 
the  picture  remarkably  complete. 

Apart,  however,  from  the  causes  we  have  just 
enumerated,  and  others  to  be  noticed  below,  we  must 
emphasise  the  fact  once  again  that  mental  predisposition 
is  a  sine  qua  non  for  the  development  of  tic. 

1  GRASSET,  "  Tic   du   colporteur ;   spasme   polygonal   post-profes- 
sionnel,"  Nowu.  icon,  de  la  Salpetriere,  July — August,  1897,  p.  217. 
3  ALFRED  DE  VIGNY,  Servitude  militaire,  chap.  vi. 


CHAPTER    VI 

PATHOLOGICAL    ANATOMY 

OUR  ignorance  of  the  pathological  anatomy  of  tic 
is  profound.  Hitherto  all  the  cases  labelled  tic 
in  which  a  post-mortem  examination  has  been  made 
have  in  reality  been  spasmodic  affections  differing 
essentially  from  the  tics  as  we  understand  them,  accord- 
ing to  the  ideas  of  Trousseau,  Charcot,  and  Brissaud. 
As  far  as  we  are  aware,  not  a  single  sectio  of  a  genuine 
case  of  tic  is  on  record  where  a  lesion,  of  whatever 
nature  or  whatever  site  it  be,  has  been  discovered  to 
which  the  tic  might  be  attributed.  Either  an  autopsy 
is  not  obtained,  or  if  it  is,  no  special  abnormality  is 
remarked,  or  else  the  diagnosis  has  been  erroneous  and 
the  changes  described  have  not  been  those  of  tic. 

It  would  be  premature,  of  course,  to  conclude  that 
tic  is  a  disease  sine  materia.  The  affirmation  is  quite 
unwarranted.  As  is  the  case  with  numbers  of  neuroses 
and  psychoses,  we  must  for  the  present  rest  satisfied 
to  observe  symptoms;  the  mystery  of  their  morbid 
anatomy  will  remain  unsolved  until  our  methods  of 
investigation  attain  perfection.  Magnan 1  says  of 
"  superior  degenerates  "  that  clinical  observation  reveals 
functional  disorders  so  distinct  and  so  invariable  that 
it  is  impossible  they  should  not  be  the  outcome  of  some 
pathological  modification  of  the  organism.  It  is  true 
he  declares  in  another  place  2  that  the  mentally  unstable 

1  MAGNAN,  loc.  cit.  p.  144. 
1  Id.,  loc.  cit.  p.  145. 
108 


PATHOLOGICAL  ANATOMY  109 

have  all  a  family  likeness,  consisting  not  in  identity  of 
well-defined  anatomical  lesions,  but  in  similarity  of  func- 
tional derangements.  As  it  is,  from  the  motor  point 
of  view  tic  is  a  functional  act,  and  the  governing  centre 
is  a  functional  centre  that  has  become  hypertrophied,  so 
to  speak,  by  being  educated  to  excess.  This  physio- 
logical centre  must  not  be  confused  with  the  "  centre  " 
of  current  anatomical  terminology  ;  it  does  not  exercise 
an  exclusive  control  over  a  particular  territory — several 
such  may  co-exist  in  a  single  anatomical  area. 

Our  lack  of  knowledge  concerning  the  precise 
localisation  of  these  functional  centres  is  paralleled  by 
our  ignorance  as  to  the  manner  of  their  involvement. 

Noir  has  prudently  observed  that  the  manifesta- 
tion of  co-ordinated  tics  in  cases  of  widespread  cerebral 
disease,  and  the  frequent  occurrence  of  the  most 
extensive  and  complex  varieties  in  patients  who  have 
suffered  from  meningeal  affections,  suggest  their  cerebral 
origin.  On  these  points,  however,  anatomo-patho- 
logical  information  is  to  seek,  and  for  that  matter 
the  direct  dependence  of  such  an  habitual  movement  as 
a  .co-ordinated  tic  upon  one  lesion  is  scarcely  within  the 
bounds  of  probability.  Tic  pertains  to  a  psychical  rather 
than  to  a  motor  sphere,  and  is  to  be  regarded  as  a 
disease  of  the  will. 

With  this  statement,  and  with  the  expression  of  our 
hope  that  subsequent  work  will  aid  in  the  elucidation 
of  the  question,  we  shall  close  the  chapter  of  the  tic's 
pathological  anatomy.  It  may  not  prove  superfluous, 
however,  to  indicate  why  and  how  the  facts  gleaned 
from  pathology  and  supposed  to  be  in  harmony  with 
the  clinical  picture  of  tic  should  be  allocated  to  other 
morbid  entities. 

In  several  cases  considered  to  be  tics  of  the  face, 
cortical  lesions  have  been  discovered  at  the  posterior 
end  of  the  second  frontal  convolution,  in  the  centre  for 


I io          TICS  AND    THEIR    TREATMENT 

voluntary  and  co-ordinated  movements  of  the  contra- 
lateral  facial  muscles.  It  has  become  classical  to  cite 
an  example  described  as  long  ago  as  1864  by  Debrou  * 
under  the  title  "  painless  facial  tic,"  but  a  glance  at 
the  observation  suffices  at  once  to  negative  its  classi- 
fication as  a  tic,  and  to  justify  the  diagnosis  of  a  spasm 
of  a  quite  peculiar  sort. 

On  February  26,  1862,  a  porter,  aged  forty-nine,  was  suddenly 
seized  with  an  "attack  of  the  nerves,"  and  at  its  close  lost  his  speech. 
When  examined  at  the  hospital  two  days  later,  he  was  found  to  have 
full  use  of  his  limbs,  understood  perfectly  all  that  was  said  to  him, 
and  evinced  great  impatience  at  being  unable  to  respond  except  in 
writing  or  by  gesture.  He  made  signs  to  indicate  that  his  head  was 
paining  him,  and  that  he  had  difficulty  in  swallowing.  In  addition, 
abrupt,  forcible,  and  rapid  movements  of  the  facial  muscles  on  the 
right  side  were  taking  place  ;  the  angle  of  the  mouth  and  the  outer 
angle  of  the  palpebral  aperture  were  being  dragged  on  ;  the  external  ear 
was  elevated,  or  moving  to  and  fro  ;  the  platysma  was  twitching  visibly 
and  the  hyoid  bone  so  acted  on  as  to  pull  up  the  larynx  spasmodically. 
The  exhibition  was  an  exact  replica  of  the  effect  produced  in  animals 
by  intracranial  galvanisation  of  the  facial  nerve.  Moments  of  absolute 
repose  alternated  with  periods  of  spasm  of  a  few  seconds'  duration, 
which  addressing  or  handling  the  patient  seemed  to  aggravate.  There 
was  synchronous  spasm  in  the  masseter  muscles,  resulting  in  elevation 
of  the  inferior  maxilla.  No  other  region  of  the  body  was  affected. 

On  the  night  of  March  2  the  attacks  of  spasm  and  of  pain  increased 
in  intensity  and  frequency,  without  any  other  change  in  their  nature.  The 
patient's  mind  remained  unclouded,  and  as  he  was  still  deprived  of  the  faculty 
of  speech,  he  again  indicated  in  writing  the  severity  of  his  sufferings.  About 
eleven  o'clock  at  night  the  situation  became  more  distressing  ;  he  began 
to  be  profoundly  agitated,  then  passed  into  a  more  or  less  maniacal  state, 
in  which  his  limbs  were  involved  in  powerful  muscular  spasms,  his  eyes 
rolled  in  their  sockets,  and  his  respiration  commenced  to  be  stertorous, 
while  the  violence  of  his  struggles  necessitated  the  intervention  of  two 
assistants  to  control  him.  An  hour  or  two  later,  during  one  of  these 
attacks  the  end  came. 

At  the  autopsy,  under  the  arachnoid  and  spreading  over  the  left  hemi- 
sphere at  the  junction  of  its  anterior  and  middle  thirds,  was  a  large 
blood-clot,  dark,  coagulated,  and  free  in  the  cerebral  substance,  which 

1  DEBROU,  "  Sur  le  tic  non  douloureux  de  la  face,"  Arch.  gen.  dt 
med.,  June,  1864,  p.  641. 


PATHOLOGICAL   ANATOMY  in 

it  had  penetrated  for  a  depth  of  about  one  centimetre.  It  appeared 
to  be  of  about  four  or  six  days'  formation,  and  probably  dated  from 
the  incipient  "  attack  of  the  nerves."  Painstaking  scrutiny  of  the 
cerebellum  and  cranial  nerves  failed  to  reveal  any  further  pathological 
condition. 

To  tell  the  truth,  we  are  not  averse  to  wagering 
that  to-day  the  opinion  of  the  surgeon  would  be 
invited  on  a  similar  case,  where  the  motor  reactions 
of  the  so-called  tic  are  manifestly  based  on  a 
Jacksonian  type. 

In  a  case  recorded  by  Chipault  and  A.  Chipault,1  and 
characterised  by  brief  epileptiform  attacks  involving 
the  left  side  of  the  face,  cerebral  exploration  proved 
ineffectual,  but  at  the  postmortem  a  subcortical  glioma 
of  the  size  of  a  cherry  was  discovered  underneath  the 
posterior  end  of  the  second  frontal  convolution.  Is  a 
case  of  cerebral  tumour  to  be  labelled  tic  ? 

It  is  quite  exceptional,  in  fact,  for  lesions  of  the 
cortical  facial  centres  to  give  rise  to  muscular  move- 
ments suggesting  facial  tic.  Take  another  instance : 

An  interesting  case  (says  Brissaud),  and  one  that  is  everywhere 
quoted,  is  reported  by  Schultz,  in  which  an  aneurism  of  the  vertebral 
artery,  at  the  point  where  the  basilar  arises,  compressed  the  trunk  of 
the  left  facial  nerve,  and  occasioned  a  "  tic"  of  ten  years'  duration.  As 
a  matter  of  fact,  one  could  not  have  a  better  example  of  spasm  pure  and 
simple. 

Fe're' 2  cites  the  following  incident  in  support  of  the 
contention  that  encephalic  trauma  may  engender  a  tic  : 

A  man  in  falling  on  his  head  sustained  an  injury  to  the  cranial 
vault  over  the  posterior  section  of  the  left  parietal  bone,  at  a  spot 
exactly  corresponding  to  the  posterior  part  of  the  angular  gyrus,  and 
immediately  became  afflicted  with  a  convulsive  tic  of  the  zygomatics 
and  orbicularis  palpebrarum  on  the  right.  Conformably  to  Ferrier's 
experimental  localisation  of  the  motor  centre  for  the  eye  muscles  and 

1  CHIPAULT  AND  A.  CHIPAULT,  Rev.  neurologique,  1893,  p.  149. 
*  F£R£,  Arch,  de  physiol.,  1876,  p.  267. 


ii2          TICS  AND    THEIR    TREATMENT 

lids  in  the  angular  gyrus,  irritation  of  this  centre  by  the  cranial  injury 
was  the  diagnosis  made. 

The  proffered  interpretation  of  the  motor  phenomena 
by  cortical  excitation  is  entirely  justifiable,  but  no 
convulsion  consecutive  to  traumatism  can  ever  pass 
muster  as  a  tic. 

A  no  less  frequently  quoted  experiment  of  Gilbert, 
Cadiot,  and  Roger,1  supposed  to  confirm  certain  results 
obtained  by  Nothnagel,  is  now  a  standard  case  in  the 
history  of  tic  hypotheses.  The  animal  in  question  was 
a  dog  affected  with  spasmodic  twitches  of  the  ear,  which 
the  successive  removal  of  cortical  facial  centre,  internal 
capsule,  corpora  striata,  and  cerebellum,  signally  failed 
to  alleviate,  and  which  disappeared  only  with  the  de- 
struction of  the  corresponding  nucleus  in  the  pons. 
Their  inability  to  find  any  anatomical  change  deter- 
mined the  experimenters  in  favour  of  the  view  that 
the  trouble  was  functional,  and  they  described  it  as  a 
tic. 

It  would  be  foolhardy  to  deny  the  existence  of  a 
lesion  on  the  ground  that  it  was  not  discovered. 
Negative  findings  of  this  sort  are  valueless.  The  sole 
conclusion  to  draw  from  the  incident  is  the  all-important 
role  played  by  the  bulbar  centres  in  the  production  of 
convulsive  movements,  which  are  in  such  circumstances, 
of  course,  nought  else  than  spasms. 

Compression  of  cranial  nerves  by  tumours  or  aneur- 
isms of  the  base  has  been  the  cause  of  symptoms 
imagined  to  be  identical  with  those  of  tic.  The  case 
of  intracranial  neoplasm  mentioned  by  Oppenheim,  in 
which  irritation  of  the  upper  branch  of  the  trigeminal 
was  accompanied  by  homolateral  facial  contraction,  is 
wholly  comparable  to  the  so-called  "  tic  douloureux." 

No    less   positive   is   our   refusal  to   accept   as   tics 

1  GILBERT,  CADIOT,  AND  ROGER,  "  Note  sur  1'origine  bulbaire  du  tic 
de  la  face,"  Rev.  de  mtd.,  1890,  p.  431. 


PATHOLOGICAL  ANATOMY  113 

spasmodic  contractions  in  association  with  or  subse- 
quent to  facial  palsy  or  contracture  of  peripheral  or 
central  origin.  They  are  spasms,  not  tics.  Cruchet,  for 
instance,  describes  indifferently  as  labial  tic  or  inter- 
mittent labial  hemispasm  clonic  elevation  or  depression 
of  the  oral  aperture  developing  in  central  facial  paralysis, 
especially  in  children.  As  example  he  refers  to  the  case 
of  a  child  in  whom  an  ictus  at  the  age  of  three  years  was 
followed  by  a  typical  spastic  hemiplegia  on  the  left  side, 
with  athetoido-choreic  movements  chiefly  in  the  arm. 

At  first  the  left  side  of  the  face  was  flaccid  and  deviated  in  the 
other  direction,  but  at  the  time  of  examination  it  presented  no  unusual 
feature  beyond  a  continual  twitching,  a  real  convulsive  tic,  of  the 
upper  lip. 

Now,  whatever  a  facial  convulsion  of  apoplectic 
origin,  secondary  to  facial  palsy  and  accompanied  with 
spastic  hemiplegia  and  athetosis,  may  be,  it  is  at  all 
events  no  tic. 

Take  one  more  case,  given  by  Buss  J  as  "  convulsive 
tic  of  the  left  side  of  the  face." 

The  patient  was  an  atheromatous  subject,  with  cardiac  hypertrophy, 
bronchitis,  and  emphysema.  When  he  first  came  under  observation  at 
the  hospital,  his  eyelids,  cheek,  and  buccal  commissure  were  the  seat 
of  painless  clonic  contractions,  which  a  month  later  were  complicated 
by  giddiness,  vomiting,  inability  to  stand  or  walk,  lancinating  pain 
over  the  right  side  of  the  face,  weakness  of  the  right  limbs,  and  left 
facial  paresis,  and  had  become  fugitive  and  insignificant.  Loss  of  con- 
sciousness was  followed  by  flaccidity  of  all  four  extremities,  hyperpyrexia, 
and  death.  The  sectio  showed  a  haemorrhage  of  the  dimensions  of  a 
pigeon's  egg  which  had  destroyed  the  left  half  of  the  pons,  and  an 
atheromatous  dilatation  of  the  left  posterior  cerebellar  artery,  impinging 
at  one  spot  on  the  seventh  and  eighth  nerves  of  the  same  side.  Micro- 
scopical examination  of  their  trunks  and  of  the  facial  area  in  the  pons 
disclosed  no  abnormality. 

The  pathological  anatomy  of  this  case  indicates  its 
nature  unmistakably,  and  its  symptomatology  and  evo- 
1  Buss,  quoted  by  CRUCHET,  These  de  Paris,  p.  19. 

8 


114         TICS  AND    THEIR    TREATMENT 

lution,  moreover,  do  not  bear  the  remotest  resemblance 
to  those  of  tic. 

In  the  opinion  of  Debrou,1  convulsive  tic  is  a  func- 
tional derangement  of  a  motor  nerve,  analogous  to  the 
neuralgia  of  a  sensory  one.  To  strengthen  his  argu- 
ment he  relied  on  such  cases  as  those  of  Romberg, 
Schultz,  Bosenthal,  Oppolzer,  where  disease  of  neigh- 
bouring structures  (enlarged  glands,  otitis  media,  caries 
of  the  temporal  bone,  etc.)  was  the  agent  in  the 
production  of  muscular  twitches  in  the  domain  of  the 
facial.  In  our  view,  however,  they  are  simply  spasms 
provoked  by  irritation  on  the  centrifugal  path  of  a 
reflex  bulbar  arc. 

The  slight  contractions  occasionally  seen  both  on 
the  paralysed  and  on  the  non-paralysed  side  in  the 
secondary  contracture  stage  of  facial  palsy — a  con- 
dition noted  by  Duchenne  of  Boulogne,  Hitzig,  and 
others,  and  distinct  from  fibrillary  twitching — are 
nothing  more  than  spasms,  and  the  same  obtains  where 
the  palsy  is  consecutive  to  affections  of  the  ear. 

Chipault  and  le  Fur  recently2  communicated  to 
the  Academy  of  Medicine  a  case  of  intermittent  attacks 
of  acute  pain  in  the  right  hypochondriac  region, 
associated  with  violent  contractions  of  the  muscles  of 
the  right  abdominal  wall,  which  they  described  as  a 
tic  comparable  to  tic  douloureux  of  the  face.  It  was 
seen  at  the  subsequent  operation  that  the  eighth, 
ninth,  and  tenth  posterior  spinal  roots  on  the  right 
side  were  surrounded  in  their  passage  through  the 
meninges  by  a  patch  of  matted  and  cicatricial  arach- 
noiditis, dissection  of  which  was  instrumental  in  effecting 
immediate  relief. 

1  DEBROU,  loc.  cit.  p.  641. 

1  CHIPAULT  AND  LE  FUR,  "  N6vralgie  des  huitteme,  neuvteme,  et 
dixieme  racines  dorsales  avec  tic  abdominal,"  Gaz.  des  kdpitaux, 
March  20,  1902,  p.  325. 


PATHOLOGICAL   ANATOMY  115 

One  could  not  desire  a  more  typical  example  of 
reflex  spasm,  the  area  of  irritation  in  this  case  being 
situated  at  a  point  on  the  centripetal  arc  close  to  the 
medullary  centre. 

We  may  be  allowed  to  quote  a  last  case  from  Cruchet : 

A  little  phthisical  girl,  four  and  a  half  years  old,  began  to  complain 
of  headache,  and  in  the  course  of  the  next  day  became  delirious.  Three 
days  later  the  delirium  gave  place  to  generalised  convulsive  seizures 
affecting  chiefly  the  arms,  and  more  pronounced  on  the  left  side.  Simul- 
taneously a  tic  of  the  right  side  of  the  face  was  observed,  distinguished 
by  raising  of  the  upper  lip  and  closure  of  the  palpebral  aperture.  Sleep 
brought  no  modification  in  its  train.  Up  to  this  stage  a  very  feeble 
degree  of  contracture  of  the  jaw  muscles  had  been  noted,  but  this 
speedily  became  accentuated  to  such  an  extent  that  nasal  feeding  had 
to  be  adopted.  Some  hours  previous  to  the  child's  death  the  tic  dis- 
appeared, only  occasional  slight  convulsive  twitches  of  the  right  arm 
remaining.  Consciousness  was  maintained  to  the  last  minute. 

At  the  autopsy  the  characteristic  appearances  of  tuberculous  meningitis 
were  found  :  the  base  of  the  brain  at  the  anterior  perforated  spot  and 
origin  of  the  sylvian  artery  was  covered  with  gelatinous  purulent  patches, 
the  colour  of  prune  juice,  which  extended  backwards  to  the  pons  ;  one 
in  particular  had  enveloped  the  basilar  trunk  and  sent  out  a  prolongation 
on  the  right  side,  which  surrounded  the  sixth,  seventh,  and  eighth  nerves 
at  their  point  of  emergence. 

For  our  part,  we  cannot  apply  the  word  tic  to  the 
convulsive  phenomena  of  tuberculous  meningitis.  If 
localised  spasms  occurring  in  the  course  of  a  grave 
illness,  associated  with  fever,  headache,  and  delirium, 
with  contractures  and  generalised  convulsions,  and  if  the 
spasmodic  manifestations  of  rapidly  fatal  pyrexias,  are 
all  to  be  denominated  tics,  then  the  term  has  no  longer 
any  significance,  and  it  would  be  wiser  to  give  it  at 
once  its  quietus. 

We  are  well  enough  aware  that  Cruchet  believes 
there  is  a  "convulsive  tic  symptom";  in  other  words, 
certain  symptoms  in  such  and  such  a  disease  appear  in 
the  guise  of  convulsive  tic,  "  a  movement  or  combination 
of  movements  representing  in  a  clonic  fashion  a  physio- 


ii6         TICS  AND   THEIR    TREATMENT 

logical  act."  Nevertheless,  we  are  not  convinced  that 
the  convulsive  movements  of  Cruchet's  patients  exhibit 
the  sequence  of  "  regulated  physiological  acts." 

He  further  draws  an  analogy  between  the  foregoing 
case  and  the  partial  convulsions  of  toxaemias,  cerebral 
tumours,  etc.,  "  transient  convulsions  supervening  in 
the  course  of  acute  or  chronic  affections,  and  readily 
recognisable."  In  exceptional  circumstances  they  may 
"  assume  the  form  of  convulsive  tic."  In  strict  truth 
the  form,  may  be  the  same,  but  examination  of  the 
patient  will  soon  demonstrate  that  the  two  are  alike 
merely  in  appearance,  and  compel  the  reconsideration 
of  an  immature  diagnosis. 

Our  position  is  that  tic  is  more  than  a  symptom — it 
is  a  symptom-complex.  Cruchet's  definition  of  con- 
vulsive tic  just  quoted  is  by  itself  insufficient ;  the 
additional  and  indispensable  factor  is  the  characteristic 
mental  defect,  of  which  so  illuminating  an  exposition 
was  given  by  Charcot. 

Finally,  the  knowledge  derived  from  the  pathological 
investigation  of  myoclonus  and  polyclonus  does  not  of 
necessity  throw  light  on  the  morbid  anatomy  of  tic. 

In  the  case  of  an  epileptic  who  suffered  from 
myoclonus  in  his  last  years,  ischsemic  degenerations 
were  found  by  Rossi  and  Gonzales  disseminated  through- 
out the  brain,  especially  in  the  rolandic  area,  but  any 
inference  to  hold  good  for  the  tics  would  be  premature. 

The  term  polyclonus  has  been  employed  by  Murri 
to  designate  a  succession  of  clonic  contractions  of  the 
limbs,  due  to  the  existence  of  punctiform  haBmorr- 
hages  or  areas  of  softening  scattered  throughout  the 
rolandic  cortex.  The  character  of  the  motor  reaction 
in  these  cases,  however,  bears  no  resemblance  either 
to  tic  or  to  chorea,  although  the  fact  of  the  relation 
between  diffuse  cortical  lesions  and  convulsive  move- 


PATHOLOGICAL   ANATOMY  117 

ments  is  calculated  to  enhance  the  difficulties  of 
diagnosis. 

Vincenzo  Patella l  has  recently  called  attention  to  a 
case  of  polyclonus  in  which  the  disappearance  of  the 
symptoms  during  sleep  suggested  their  purely  functional 
origin,  but  histological  examination  of  the  rolandic 
grey  matter  at  a  subsequent  period  revealed  the  presence 
of  numerous  foci  of  degeneration.  "We  are  as  yet, 
however,  far  from  grasping  the  real  meaning  of  such 
symptoms,  which,  moreover,  from  the  clinical  stand- 
point, cannot  always  be  assimilated  to  those  of  the 
tics.  Conclusive  anatomical  information  is  therefore 
still  being  awaited. 

The  functional  nature  of  the  movements  we  have 
had  under  discussion  is  unfortunately  an  obstacle  in 
the  way  of  our  early  knowledge  of  their  pathology. 
As  long  as  we  remain  ignorant  of  the  actual  cause  of 
the  neuroses  and  psychoses,  so  long  will  the  pathological 
anatomy  of  tic  continue  a  sealed  book.  All  that  has 
been  written  on  this  topic  hitherto  really  concerns  spasm 
and  other  convulsive  affections  secondary  to  irritation 
of  nerve  centres  or  conductors.  If  we  may  venture 
to  express  an  opinion,  it  is  that  we  should  not  be 
surprised  if  post-mortem  examination  rest  constantly 
negative.  As  a  matter  of  fact,  we  do  not  favour  the 
view  that  the  phenomena  depend  on  an  acquired  lesion ; 
rather  are  we  inclined  to  believe  that  they  represent 
some  congenital  anomaly,  some  arrest  or  defect  in  the 
development  of  cortical  association  paths  or  subcortical 
anastomoses,  minute  teratological  malformations  that 
our  medical  knowledge  is  still  unhappily  powerless  to 
appreciate. 

1  PATELLA,  "  Studio  anatomo-patologico  e  clinico  sul  policlono," 
II policlinico,  vol.  viii.  November,  1901,  p.  535. 


CHAPTER  VH 

STUDY  OF  THE  MOTOR  REACTION 

general  characters  of  the  motor  reaction  con- 
stituting  the  objective  manifestation  of  tic  form 
the  subject  of  previous  analysis  in  the  chapter  on 
pathological  physiology.  It  is  our  present  intention  to 
approach  them  from  the  semiological  point  of  view. 

To  give  a  description  of  the  motor  disturbance  of 
universal  applicability  is  evidently  to  attempt  the 
impossible.  The  modifications  of  functional  acts  are 
legion,  and  in  the  case  of  tic  anomalies  of  muscular 
contraction  vary  not  merely  with  the  individual,  but 
in  the  individual.  Each  tics  after  his  own  fashion ; 
and  no  two  tics  are  ever  exactly  interchangeable.  As 
Trousseau  was  wont  to  say,  "the  disease  in  a  sense 
forms  part  of  the  constitution  of  the  person  affected." 

THE  TYPE   OF   MOTOR    REACTION— CLON  1C    TIC    AND 
TONIC  TIC 

The  motor  reaction  may  be  either  clonic  or  tonic  in 
type.  Clonic  tics  are  distinguished  by  more  or  less 
abrupt  contractions,  separated  by  longer  or  shorter 
intervals  of  relaxation  or  repose.  The  duration  of  a 
clonic  tic  convulsion  may  be  exceedingly  brief,  though 
perhaps  not  so  brief  as  the  instantaneous  "  electric " 
twitches  of  a  spasm,  which  have  the  extreme  rapidity 
of  pure  reflex  phenomena.  Exception  ought  to  be 
made  for  the  face,  no  doubt,  seeing  that  the  suddenness 

118 


STUDY  OF  THE  MOTOR  REACTION    ng 

of  the  movements  in  facial  tic  is  precisely  what  com- 
plicates the  diagnosis  between  it  and  facial  spasm,  as 
we  shall  see.  In  the  limbs,  the  variations  appear  to 
stand  in  close  relation  to  the  nature  of  the  primary 
factor,  the  mental  condition  of  the  patient,  and  the 
mode  of  reaction  peculiar  to  him.  The  quickness  with 
which  the  reaction  occurs  increases  in  proportion  to 
the  length  of  time  the  tic  has  existed,  although  once 
it  has  become  habitual,  any  further  change  is  rather  in 
the  direction  of  additional  complexity. 

Sometimes  a  relative  deliberateness  of  execution 
raises  suspicions  as  to  the  accuracy  of  the  diagnosis. 
In  the  case  of  a  child  with  several  tics,  one  affecting 
the  mouth  in  particular,  Guinon  was  struck  by  the 
slowness  of  the  muscular  contractions. 

To  begin  with  (he  says),  the  mouth  was  opened  gradually,  but  as 
soon  as  the  limit  of  separation  of  the  maxillae  was  reached,  it  was 
immediately  closed,  without  remaining  even  for  a  moment  in  the  extended 
position,  as  one  would  have  expected  had  there  been  a  tonic  contraction 
of  the  infrahyoid  muscles. 

Cases  of  this  kind,  however,  are  not  really  instances 
of  the  tonic  variety. 

One  of  us  has  had  the  opportunity  of  observing  a 
young  woman  afflicted  with  a  curious  combination  of 
motor  disorders,  akin  no  less  to  the  clonic  form  of  tic 
than  to  the  gesticulations  of  chorea  and  the  undulatory 
movements  of  athetosis.  Their  resemblance  to  the 
clinical  type  described  by  Brissaud  under  the  name  of 
variable  chorea  is  noteworthy,  a  distinguishing  feature, 
however,  being  the  sluggishness  of  the  muscular  con- 
tractions, which  may  well  be  a  reflex  of  the  patient's 
mental  inertness. 

Mademoiselle  R.,  a  young  woman  twenty-six  years  old,  is  a  small 
and  delicate  creature  with  slender  limbs  and  tapering  fingers.  She 
is  extremely  myopic,  but  her  general  health  is  excellent,  and  there  is 


120         TICS  AND    THEIR    TREATMENT 

nothing  to  suggest  that  she  is  suffering  from  organic  disease  of  the 
nervous  system.  Apart  from  the  fact  that  her  parents  are  rather  "  nervous," 
the  family  history  is  negative. 

Since  the  age  of  twelve  she  has  been  subject  to  various  tics  of  the 
face  and  head.  She  wrinkles  her  forehead  and  moves  her  scalp  to  and 
fro,  and  sometimes  she  turns  her  head  slowly  and  steadily  towards  the 
left  side,  raising  her  eyes  up  and  to  the  left  at  the  same  moment.  Head 
and  eyes  forthwith  resume  their  normal  position.  The  deliberateness 
of  the  act  is  altogether  exceptional.  If,  however,  she  happens  to  be 
wearing  her  hat — which  is  remarkable  for  its  size,  weight,  and  un- 
wieldiness — the  gesture  is  repeated  in  a  quick  and  jerky  manner. 
Any  diversion,  such  as  reading,  knitting,  listening  to  a  conversation, 
especially  if  she  feels  she  is  not  being  noticed,  will  augment  the  intensity 
of  the  movements,  which  the  thought  of  being  observed,  or  the 
awakening  of  her  interest,  or  rest  in  bed,  or  sleep,  has  the  effect  of 
abbreviating  or  checking. 

Our  earliest  step  was  to  confiscate  the  offending  hat,  and  this  had 
the  instantaneous  result  of  diminishing  the  violence  and  frequency  of 
the  tic,  which  the  subsequent  practice  of  appropriate  exercises  entirely 
dispelled. 

If  now  we  direct  our  attention  to  the  psychical  aspect  of  the  case, 
we  are  struck  with  the  goodness,  devotion,  and  disinterestedness  of  our 
patient.  Her  one  concern  is  for  the  welfare  of  others,  and  she  is  indifferent 
to  the  pleasures  'of  literature,  art,  games,  or  even  work.  All  that  is 
required  of  her  she  performs  with  docility,  but  never  with  animation. 
The  extent  of  her  passiveness  is  seen  in  her  childlike  acceptance  of  her 
parents'  wishes.  Her  temperament  is  neither  gay  nor  sad,  but  merely 
dull.  Indolence  and  maladroitness  predominate  in  all  her  actions,  and 
reveal  themselves  in  the  curious  awkwardness  and  nonchalance  that 
characterise  the  execution  of  even  the  simplest  movement.  She  is 
essentially  of  a  very  unstable  nature,  but  its  torpidity  is  no  less  obvious 
than  its  instability.  If  there  is  no  abruptness  in  her  acts,  it  is  equally 
true  that  she  is  never  still.  She  cannot  maintain  any  given  attitude  ; 
she  cannot  fix  her  gaze  on  any  particular  object.  Her  restlessness  is 
such  that  her  position  is  changed  from  moment  to  moment,  however 
slowly  and  imperceptibly.  Her  eyes  are  only  half  opened  ;  as  she  speaks, 
her  lips  are  scarcely  seen  to  move. 

It  has  been  a  laborious  and  protracted  task  to  teach  her  to  sit 
motionless  with  her  hands  in  front  of  her,  and  no  less  unremitting  effort 
has  been  required  to  make  her  open  her  mouth  properly,  or  turn  her 
head  naturally  from  side  to  side. 

In  some  ways  the  endless  movements  of  her  hands  and  fingers — she 
never  ceases  playing  with  her  dress  or  her  gloves  or  her  handkerchief — 
are  vaguely  reminiscent  of  those  of  athetosis,  and  on  the  left  side  especially, 


STUDY  OF  THE  MOTOR  REACTION     121 

if  they  become  a  little  brisker,  there  is  slight  hyperextension  of  the 
phalanges.  She  reads  aloud  in  a  low,  colourless,  monotonous  tone  of 
voice,  without  punctuation  or  accent,  articulating  the  syllables  defectively 
and  slurring  the  ends  of  the  words.  At  the  finish  of  each  paragraph 
comes  a  halt,  as  if  from  fatigue,  and  on  command  a  fresh  start  is  made 
with  the  same  careless  indifference.  As  for  the  lower  extremities,  the 
tale  is  identical.  Mademoiselle  R.  cannot  stand  upright.  She  rests 
on  either  one  leg  or  the  other.  Her  left  foot  is  never  flat  on  the 
ground,  but  sometimes  on  the  inner  border,  sometimes  on  the  outer. 
The  faulty  attitude  is  readily  enough  corrected,  though  she  declares  she 
is  ignorant  of  it.  It  is  a  sort  of  half  clonic,  half  tonic,  tic  of  the  foot, 
whose  slowness  is  on  a  par  with  that  of  all  her  other  acts. 

It  is  because  clonic  tics  are  so  easily  recognised  that 
they  are  the  most  familiar,  but  we  must  not  ignore 
another  variety — viz.  the  tonic  tics,  corresponding  to 
the  tonic  form  of  convulsion. 

Tonic  tic  is  of  common  occurrence  in  cases  of 
mental  torticollis.  In  that  disease  rotation  of  the 
head  may  be  sustained  for  a  considerable  length  of 
time  without  interruption,  showing  the  permanent 
nature  of  the  muscular  contraction.  Strictly  speaking, 
we  are  concerned  not  with  a  sudden  gesture,  but  with 
an  attitude.  Abundant  evidence  is  forthcoming  to 
substantiate  its  mental  origin,  and  it  may  therefore  be 
described  as  an  attitude  tic.  Among  other  instances  of 
tonic  tics  may  be  specified  the  affection  of  the  masseters 
known  as  mental  trismus  (Raymond  and  Janet),  or  that 
continuous  contraction  of  the  orbicularis  which  keeps  the 
eye  half  closed,  though  it  may  momentarily  disappear 
under  the  influence  of  the  will — a  tonic  blinking  tic. 
0.  and  young  J.  have  already  supplied  examples  of 
attitude  tics,  and  reference  may  further  be  made  to 
another  of  our  patients l : 

Sometimes  the  mouth  is  drawn  directly  and  completely  to  the  left, 
more  usually  to  the  right  ;  at  other  times  simultaneous  contraction  of 

1  FEINDEL,  "  Spasmes  grima5ants  de  la  face,"  Revue  de psychologic, 
April,  1899,  p.  1 1 8. 


122          TICS  AND    THEIR    TREATMENT 

the  upper  and  lower  lips  takes  place,  constituting  a  sufficiently  faithful 
reproduction  of  the  grimace  made  by  a  child  in  the  attempt  to  refrain 
from  crying  ;  at  other  times  still,  imperfect  closure  of  the  lids  and  upward 
deviation  of  the  eyes  bear  a  resemblance  to  children's  imitation  of  a 
blind  man.  Displacement  of  the  mouth  to  the  right  is  the  movement 
of  longest  duration,  and  while  it  persists  the  patient  is  capable  of  stuttering 
speech,  without  relaxing  her  lips.  The  other  tics  last  but  a  few  seconds, 
while  all  vanish  if  she  laughs  or  opens  her  mouth  wide  to  exhibit  her 
tongue.  They  follow  each  other  at  irregular  intervals,  and  during  the 
moments  of  rest  the  face  resumes  its  normal  expression. 

Cruchet,  as  has  been  already  remarked,  has  criticised 
the  use  of  the  term  attitude  tic,  on  the  ground  that 
the  adoption  of  an  attitude,  however  vicious  it  be,  need 
not  be  the  outcome  of  a  convulsion.  Doubtless ;  but 
it  is  no  less  true  that  a  tonic  convulsion  may  "  take 
shape  " — e.g.  the  arc  de  cercle  of  hysteria,  the  phenomena 
of  catatonia  and  catalepsy,  etc.  Of  course  if  the  word 
tic  is  to  be  synonymous  with  intermittent  twitching, 
then  it  is  inapplicable  in  this  class  of  case ;  but  if  our 
connotation  of  the  term  be  accepted,  we  must  find  an 
expression  that  will  serve  to  differentiate  between  tonic 
and  clonic  varieties.  We  are  not  aware  of  any 
particular  advantage  in  describing  the  condition  as  a 
permanent  contraction,  for  the  obvious  result  of  a 
permanent  contraction,  whether  it  be  clenching  of  the 
jaws,  occlusion  of  the  eyelids,  or  rotation  of  the  head, 
is  the  production  of  an  attitude,  a  "  position  in  which 
the  body  is  kept "  (Littre).  No  other  designation  could 
therefore  be  more  appropriate  than  attitude  tic,  or 
could  indeed  be  imagined,  seeing  that  Cruchet  himself 
ranges  mental  torticollis  among  the  tics,  and  describes 
it  as  "  an  attitude  of  defence  and  of  repose." 

It  may  sometimes  happen  that  the  manifestations  of 
stereotyped  acts  consist  in  the  assumption  of  attitudes, 
but  in  spite  of  their  affinity  to  the  tics  we  deem  it 
preferable  to  reserve  the  term  "  stereotyped  attitude  " 
or  "  akinetic  stereotyped  act "  for  cases  where  the 


STUDY  OF  THE  MOTOR  REACTION    123 

motor  reaction  is  clothed  in  the  form  of  a  normal 
movement.  As  it  is  inaccurate  to  describe  as  a  tic  a 
repeated  gesture  whose  execution  is  normal  in  degree 
and  in  rapidity,  so  the  mere  immobility  of  a  limb,  or 
the  prolonged  contraction  of  a  muscle,  ought  not  to  be 
called  an  attitude  tic  if  the  muscular  effort  does  not 
differ  from  that  which  a  healthy  person  would  make 
to  preserve  the  same  position.  In  such  circumstances 
we  say  that  it  is  a  stereotyped  gesture  or  attitude. 
For  the  diagnosis  of  tic  it  is  insufficient  to  establish 
the  existence  of  a  transient  or  permanent  muscular 
contraction,  and  to  note  the  inopportuneness  of  the 
movement ;  the  contraction  must  be  abnormal  in  itself, 
its  abruptness  unwonted  and  its  intensity  excessive — in 
short,  it  must  be  a  convulsion  ;  and  finally,  its  repetition 
must  be  continued  and  exaggerated. 

We  have  felt  that  some  such  explanation  as  the 
foregoing  is  required  to  justify  our  use  of  the  term 
-tonic  or  attitude  tic,  to  whose  close  intimacy  and 
.•association  with  the  better-known  type  pathogeny  and 
.clinical  observation  alike  bear  witness.  In  any  case 
such  terms  as  myotonus  or  myoclonus  are  too  com- 
prehensive, in  view  of  our  present-day  knowledge,  to 
specify  the  particular  motor  affection  with  which  we 
are  concerned. 

As  a  general  rule  it  is  only  one  part  or  segment  of 
the  body  that  is  immobilised  by  a  tonic  tic,  but  in 
regard  to  the  possibility  of  a  general  involvement, 
the  following  instance  l  may  be  cited,  although  we  do 
not  think  it  can  be  considered  decisive  : 

A  man  thirty-two  years  old,  who  had  recovered  from  a  first  attack 
of  mental  torticollis,  underwent  a  relapse  in  quite  a  different  form.  If 

1  BRISSAUD  AND  FEINDEL,  "  Sur  le  traitement  du  torticolis  mental 
-et  des  tics  singulaires,"  Journ.  de  neurologic,  April  15,  1899. 


124         TICS  AND    THEIR    TREATMENT 

when  walking  with  his  head  perfectly  straight  he  were  asked  to  go  round 
to  the  right,  he  instantly  appeared  to  become  rooted  to  the  spot  and 
could  not  turn  even  his  head  in  the  required  direction  ;  at  the  same  time 
he  felt  a  compression  of  his  throat  as  if  he  were  being  strangled,  and  for  a 
few  seconds  he  experienced  acute  anguish.  A  moment  later  he  was  all 
right  again,  and  his  action  unimpeded. 

Without  going  so  far  as  to  classify  this  incident  as 
a  tic,  and  without  venturing  to  assert  the  existence  of 
a  tic  of  immobility,  one  cannot  but  be  struck  with  its 
analogy  to  the  attitude  tics  of  which  we  have  been 
speaking,  and  to  catatonic  conditions  met  with  in  the 
insane,  of  which  too  the  pathogeny  presents  more  than 
one  point  of  similarity  with  that  of  this  species  of  tic. 

[In  this  connection  reference  may  be  made  to  certain 
conditions  occasionally  noted  among  those  who  tic — 
iz.  a  curious  tendency  to  maintain  abnormal  positions 
of  the  limbs  or  trunks,  and  difficulty  in  or  impossibility 
of  relaxing  various  muscles  (catatonic  aptitudes).  Patients 
are  sometimes  given  to  the  exaggerated  repetition  of 
the  ordinary  movements  of  their  members  (echokinesis), 
as  well  as  to  imitation  of  the  actions  of  others 
(echomimia).  Such  catatonic  and  echopraxic  phenomena 1 
are  not  confined  to  sufferers  from  tic,  for  they  are 
encountered  among  psychopathic  subjects  generally, 
and  indicate  defect  of  cortical  control — what  is  called  by 
Brissaud  "  passive  activity."  These  catatonic  aptitudes 
may  be  discovered  by  resort  to  clinical  tests,  such  as 
letting  the  arm  fall  from  the  horizontal  position.8] 

INTENSITY  OF  THE  MOTOR  REACTION 

The  muscular  contraction  varies  considerably  in 
intensity,  in  most  cases  exceeding  that  of  the  cor- 

1  MEIGE,  "L'aptitude  catatonique  et  1'aptitude  echopraxique  dea 
tiqueurs,"  Congres  de  Madrid,  April,  1903. 

1  MEIGE,  "  Le  phenomene  de  la  chute  du  bras,"  XIII  Congres  des 
neurologistes,  etc.,  Brussels,  1903. 


STUDY  OF  THE  MOTOR  REACTION     125 

responding  normal  movement,  and,  especially  in  tonic 
tics,  being  often  so  powerful  as  to  necessitate  the 
exertion  of  great  force  to  overcome  it.  Even  though 
one's  effort  prove  unavailing,  however,  it  is  only  needful 
to  distract  the  patient's  attention  to  perform  any  and 
every  passive  movement  with  consummate  ease. 

In  the  case  of  S.,  any  attempt  to  budge  the 
head  from  its  torticollic  position  on  the  left  evokes 
strong  muscular  resistance ;  but  engage  him  in  con- 
versation or  otherwise  divert  his  mind,  and  the  difficulty 
soon  vanishes.  By  similar  means,  the  resistance 
awakened  by  sudden  change  of  the  direction  of  passive 
rotation  will  rapidly  die  down. 

Occasionally  the  muscles  brought  into  play  surpass 
their  fellows  of  the  opposite  side  in  size  and  power, 
this  secondary  hypertrophy  being  the  natural  sequel  of 
repeated  exercise.  It  was  noted  by  Charcot  that  in 
rotatory  tics  the  disused  muscles  atrophied,  whereas 
the  affected  muscles  hypertrophied,  but  they  may  do 
so  only  in  appearance.  The  tonus  of  the  muscles  at 
the  moment  of  examination  may  create  differences 
inappreciable  during  relaxation.  Sometimes  one  comes 
across  such  expressions  as  "  paresis"  or  even  "  paralysis  " 
of  antagonistic  muscles,  and  "  contracture  "  of  those  in 
which  the  tic  is  localised.  To  draw  a  distinction 
between  slight  contracture  of  the  latter  and  mild 
paresis  of  the  former  is  a  problem  practically  always 
insoluble.  Opinion  has  been  ever  divided  on  this  point ; 
yet  some,  in  their  desire  to  harmonise  the  two,  take 
up  an  eclectic  position  and  do  not  hesitate  to  speak  J 
of  "  paralytic  contracture,"  or  "  mixed  contracture,  at 
once  active  and  passive,"  a  terminology  by  no  means 
calculated  to  simplify  the  question,  and  one  the  dis- 
cussion of  which  we  do  not  care  to  pursue. 

1  SCHEIBER,  "  liber  einen  Fall  von  durch  Spleniuskrampf  bedingten 
Torticollis,"  Wiener  med.  Wochenschrift,  1900,  p.  261. 


126         TICS  AND    THEIR    TREATMENT 

"We  should  like,  however,  to  allude  to  a  matter  of 
clinical  observation  that  we  frequently  have  had 
occasion  to  remark.  What  simulates  muscular  enfeeble- 
ment  in  the  subject  of  tic  is  often  nothing  else  than  a 
want  of  accuracy  and  adresse  in  the  performance  of  a 
given  movement.  For  instance : 

S.  enjoys  robust  health  ;  his  only  trouble  is  a  lack  of  accurate 
control  over  his  limbs.  His  execution  of  the  most  elementary  move- 
ments is  incorrect.  There  is  no  tremor,  no  jerkiness,  simply  a 
loss  of  the  sense  of  position.  He  never  knows  whether  he  is  holding 
himself  straight,  whether  his  arms  are  exactly  horizontal  or  his  shoulders 
symmetrical.  Often  he  confuses  right  and  left,  and  when  requested  to 
perform  some  act  on  one  side,  he  declares  he  is  tempted  to  perform  it 
simultaneously  on  both.  The  order  to  fold  his  arms  and  rotate  the 
upper  part  of  his  body  to  the  right  evokes  an  inconceivable  display  of 
contortions.  In  the  attempt  to  bend  his  head  and  body  backward,  fear 
of  losing  his  balance  causes  him  to  twist  and  turn  about  most  strangely, 
and  the  remark  that  all  this  he  might  avoid  by  merely  putting  one 
foot  further  back  seems  to  cause  him  infinite  surprise. 

Or  again : 

The  absence  of  precision  in  Mademoiselle  R.'s  movements,  her 
habit  of  arresting  the  action  before  attaining  the  desired  end,  are  not 
to  be  ascribed  to  any  feeling  of  discomfort,  but  to  her  ignorance  of  the 
amplitude  of  her  efforts,  and  of  the  position  of  her  limbs.  Her  acts 
are  always  feeble,  hesitating,  and  curtailed,  a  curious  mixture  of  muscular 
languor  and  vigilance,  "  as  if  she  were  afraid  of  breaking  herself."  She 
appears  to  be  constantly  seeking  some  new  position  for  herself,  and  to 
be  as  constantly  oblivious  of  her  actual  attitude.  With  eyes  closed, 
however,  she  indicates  the  relation  of  her  limbs  exactly. 

Another  example  is  furnished  by  the  case  of  L.,  to 
which  reference  is  made  on  p.  135. 

There  is  no  call  to  multiply  instances.  Enough  has 
been  said  to  demonstrate  the  frequent  occurrence,  if  not 
of  motor  inco-ordination,  at  least  of  faulty  orientation 
in  space  and  of  defective  estimation  in  regard  to  the 
range  and  intensity  of  voluntary  movements,  among 
the  subjects  of  tic.  The  topic  is  a  very  interesting  and 


STUDY  OF  THE  MOTOR  REACTION    127 

fruitful  one,  on  which  considerable  light  may  be  thrown 
by  the  application  to  it  of  the  results  of  Pierre 
Bonnier's  *  remarkable  studies  on  the  sense  of  attitudes, 
a  subject  that  we  intend  to  develop  on  another  occasion. 

FREQUENCY  AND  RHYTHM-RHYTHMIC  TIC 

The  frequency  of  the  muscular  contractions  in  tic  is  so 
very  variable  that  it  cannot  be  regarded  as  a  distinctive 
feature,  nor  is  there  any  evidence  to  show  that  it  is 
rhythmical,  as  some  would  have  us  believe.  Contrary 
to  what  obtains  in  tremor,  there  is  no  periodicity  in  the 
motor  phenomena,  even  when  the  tic  is  based  on 
derangement  of  a  function  whose  manifestations  are 
rhythmical,  such  as  the  function  of  respiration.  Con- 
ditions described  as  rhythmic  tics,  or  less  well  as 
rhythmic  spasms,  seem  to  form  a  group  by  them- 
selves ;  probably  they  do  not  belong  to  the  same 
family  as  the  tics,  indeed  in  some  cases  they  are 
symptomatic  of  encephalic  lesions,  as  in  the  spasmus 
nutans  of  infants,  or  the  rhythmic  tics  of  idiots  and 
imbeciles.  In  this  connection  the  remarks  of  Noir  are 
very  pertinent : 

We  shall  be  well  advised  to  refrain  from  drawing  too  absolute  con- 
clusions in  questions  so  difficult,  where  even  the  framing  of  an  hypothesis 
demands  prolonged  observation,  but  we  cannot  withstand  the  temptation 
to  note  the  co-existence  of  certain  of  these  tics  with  certain  definite  lesions 
recognisable  post-mortem.  This  has  been 'done  before  us  by  our  master 
Bourneville,  who  has  on  several  occasions  made  the  diagnosis  of  chronic 
meningo-encephalitis,  cerebral  sclerosis,  etc.,  from  this  association  of  rocking,, 
rotation,  and  krouomanic  movements  with  a  special  symptom-complex, 
and  verified  it  at  the  autopsy.  Nevertheless,  there  is  not  always  an 
absolute  correspondence  between  them,  wherefore  Bourneville,  with  an 
altogether  praiseworthy  scientific  reserve,  has  hesitated  to  consider  these 
tics  as  actual  symptoms  of  the  affections  alluded  to,  and  we  shall  follow 
his  prudent  example. 

1  BONNIER,  L! orientation,  Paris,  1900 ;  Le  sens  des  attitudes,  Paris 
1904. 


128          TICS  AND    THEIR   TREATMENT 

To  the  combination  of  various  rhythmical  acts  with 
hysteria  we  shall  revert  at  a  later  stage.  Under  the 
title  "  rhythmic  spasm  "  an  interesting  case  has  been 
reported  at  length  by  de  Buck,1  concerning  a  young 
woman,  free  of  hysterical  stigmata,  in  whom  convulsive 
movements  first  appeared  at  the  age  of  seven  years. 

When  she  had  attained  her  nineteenth  year  she  commenced  to  suffer 
from  attacks  of  anguish  of  some  hours'  duration,  but  disappearing  under 
the  influence  of  sleep,  in  which  she  felt  as  though  her  breathing  were 
going  to  stop  and  she  herself  were  about  to  die.  On  the  termination  of 
these  sensations  some  eighteen  months  later,  their  place  was  taken  by 
convulsive  movements  of  the  tongue,  lips,  neck,  trunk,  left  arm,  diaphragm, 
pharynx,  and  muscles  of  respiration.  These  consisted  of  clonic  rhythmical 
twitches,  each  preceded  by  an  inspiration  and  succeeded  by  an  expiratory 
ejaculation,  repeated  fifty  or  sixty  times  a  minute.  During  the  seizure 
the  tongue  was  protruded  and  deviated  to  the  left,  the  left  arm  was 
raised,  the  head  and  trunk  bent  down  and  forward.  All  day  long  the 
movements  were  continued  with  unflagging  regularity.  Rest  in  bed  was 
without  effect,  but  they  were  dispelled  by  sleep.  Distraction  and  occupation 
exercised  an  inhibitory  influence  on  them,  whereas  voluntary  control 
was  both  feeble  and  fleeting.  In  the  condition  of  the  patient  there  was 
nothing  else  abnormal  with  the  exception  of  slow,  monotonous,  and 
syllabic  speech.  Her  mental  development  was  perhaps  a  little  immature, 
but  signs  of  hysteria  were  lacking,  and  all  attempts  at  treatment  by 
suggestion  and  hypnotism  failed  of  their  object.  Death  ensued  from 
pulmonary  tuberculosis. 

De  Buck  observes  that  while  the  action  of  some  of 
the  muscular  groups  involved  in  the  rhythmic  spasm 
was,  so  to  speak,  purposive,  the  whole  did  not  con- 
stitute any  known,  conscious,  and  logical  movement. 
It  may  have  been  a  species  of  tic,  but  the  rhythmical 
sequence  of  the  convulsions  imparts  to  it  a  quite  peculiar 
character. 

ATTACKS 

A  further  mark  of  the  motor  reaction  is  the  circum- 
stance that  it  ceases  for  a  longer  or  shorter  interval, 

1  DE  BUCK,  "  Note  sur  un  cas  de  spasme  rythmique,"  Belgique 
medicate,  1899. 


STUDY  OF  THE   MOTOR  REACTION     129 

independently  of  the  tic's  localisation,  intensity,  or  form, 
the  result  being  an  alternating  series  of  "  attacks  "  and 
periods  of  respite.  In  different  patients,  and  in  the 
same  patient,  the  number  and  the  length  of  these 
attacks  are  as  variable  as  are  the  spaces  of  rest  that 
separate  them.  We  remember  a  girl  with  a  tic  consist- 
ing in  a  toss  of  the  head  repeated  perhaps  fifteen  times 
a  minute,  three  or  four  occurring  together  at  intervals 
of  one  or  two  seconds,  and  being  succeeded  by  a  re- 
latively long  pause.  The  effect  of  treatment  was  to 
modify  the  sequence  entirely,  and  to  reduce  the  tic  to 
an  isolated  jerk  reappearing  not  oftener  than  once  in 
a  quarter  of  an  hour,  and  in  itself  constituting  the 
attack.  In  another  case  the  patient's  head  used  to 
turn  to  the  left,  remain  so  for  a  moment,  then  resume 
its  ordinary  place.  After  a  time  of  repose  the  tic  began 
again,  and  even  when  the  movements  followed  each 
other  more  rapidly,  the  intervening  period  was  always 
appreciable.  On  the  other  hand,  we  have  seen  a  youth 
afflicted  with  multiple  tics  which  continued  without 
intermission  the  whole  day  long ;  the  attack  lasted, 
strictly  speaking,  from  morning  to  night,  and  any  break 
in  its  continuity  was  altogether  exceptional.  It 
might  then  be  more  exact,  perhaps,  to  use  the  epithet 
paroxysmal  in  reference  to  the  external  manifestations 
of  tics,  but  it  signifies  little  what  word  we  employ 
provided  we  are  familiar  with  the  clinical  facts. 

The  attacks  vary  with  circumstances  and  environ- 
ment. One  of  our  patients  remained  quite  free  from 
them  during  a  visit  to  the  theatre.  Tissie  had  a  young 
patient  who  did  not  tic  at  all  while  on  holiday,  but  the 
reopening  of  his  classes  was  the  signal  for  a  fresh 
outbreak.  Similarly,  no  rule  whatever  seems  to  govern 
the  duration  of  the  times  of  relief ;  they  may  never  be 
longer  than  a  few  seconds,  or  they  may  run  into  months. 
In  the  face  of  these  data  we  cannot  supply  further 

9 


130          TICS  AND    THEIR    TREATMENT 

generalisations ;  it  will  be  sufficient  if  we  impress  on 
ourselves  the  importance  of  one  fundamental  element 
in  the  constitution  of  tic — viz.  its  repetition. 


LOCALISATION  OF  THE  MOTOR  REACTION— VARIABLE 
TICS— FIXED  TICS 

The  localisation  of  the  motor  reaction  in  cases  of  tic 
is  essentially  physiological.  In  rare  instances  its  sphere 
may  be  limited  to  a  single  muscle,  if  one  muscle  only  be 
requisitioned  for  the  performance  of  a  functional  act ; 
but  it  is  very  much  more  usual  to  find  several  muscles 
contributing,  whose  synergic  contractions  fashion 
the  movement  of  which  the  tic  is  a  caricature.  If 
the  same  effect  is  yielded  by  the  action  of  either  of 
two  different  muscles  or  groups  of  muscles,  as  in  rota- 
tion of  the  head,  and  if  one  be  hindered  from  fulfilling 
its  function,  the  incidence  of  a  tic  originally  located  in 
it  will  promptly  be  transferred  to  the  other.  This 
is  the  explanation  of  the  persistence  of  rotatory  tics 
after  exclusion  of  the  sternomastoids  by  surgical 
means. 

Two  symmetrical  muscles  may  be  affected,  as  in  tics 
of  blinking  and  of  affirmation,  or  a  median  muscle,  such 
as  the  orbicularis  oris.  Much  more  frequently  the  tic  is 
unilateral  in  its  distribution,  as,  for  instance,  when  it 
involves  the  face  ;  in  this  respect  its  figuration  as  a 
functional  disturbance  is  well  exemplified,  for  expres- 
sional  movements  of  the  face  are  normally  bilateral.  A 
tic  may  settle  itself  on  two  mutually  antagonistic  muscles, 
and  manifest  its  presence  in  the  immobilisation  of  a 
limb  or  segment  of  a  limb ;  or  only  a  portion  of  a 
muscle  may  contract,  as  in  the  case  of  the  deltoid  or 
trapezius,  which  are  composed  of  bundles  anatomically 
associated  but  physiologically  independent,  and  so 
capable  of  being  functionally  differentiated  by  volun- 


STUDY   OF  THE   MOTOR   REACTION     131 

tary  education.  Fibrillary  contraction  and  tic  have 
nothing  in  common. 

Inasmuch  as  the  muscles  concerned  are  under 
voluntary  control,  and  their  contractions  such  as  the 
will  can  effect,  it  follows  that  with  adequate  practice 
the  movement  of  a  tic  can  always  be  imitated,  and 
in  predisposed  soil  imitation  tics  may  thus  take 
root;  it  is  not  always  feasible,  on  the  other  hand,  to 
counterfeit  a  spasm. 

Several  functional  muscular  territories  may  be  simul- 
taneously affected,  and  several  tics  may  follow  one 
another  in  quick  succession,  the  duration  of  any 
one  tic  on  any  one  site  being  a  more  or  less  varying 
quantity. 

We  have  already  noted  the  occurrence  of  variable 
tics.  They  appear  one  day  to  disappear  a  few  days 
later,  and  reappear  again  after  another  space.  Weeks 
or  months  may  elapse  without  any  vestige  of  them, 
until  they  suddenly  break  forth  again  unheralded.  As 
a  general  though  not  absolute  rule,  the  younger  the 
patient,  the  less  stable  his  tics.  Occasionally  they  are 
isolated,  limited,  and  stationary,  one  of  the  most  frequent 
of  this  kind  being  a  tic  of  blinking,  but  the  intimate 
alliance  between  the  motor  troubles  and  the  mental 
level  of  the  subject  helps  to  explain  why  these  tics  of 
children  are  so  changeable. 

In  the  case  of  young  J.,  for  instance,  it  was  shortly  after  attaining 
his  tenth  year  and  entering  school  that  first  he  began  to  tic,  and  thence- 
forward, at  unequal  intervals,  trunk,  arms,  shoulders,  legs,  became  in 
turn  the  seat  of  "  movements  of  the  nerves,"  while  other  more  definite 
tics  were  not  slow  in  developing. 

When  only  six  years  old  B.  exhibited  a  respiratory  tic,  which 
changed  a  year  later  to  one  of  the  tongue,  and  after  another  year  to 
one  of  the  leg  ;  at  the  age  of  twelve  he  used  to  nod  his  head  in  affirmation, 
and  this  was  eventually  succeeded  by  movements  of  negation,  etc.  He 
has  since  started  a  salaam  tic,  and  finally  a  torticollis  with  deviation  of 
the  eyes. 


132          TJCS  AND    THEIR    TREATMENT 
We  may  cite  an  analogous  case  from  Grasset : 

A    young    girl,    who    had    had    eye   and    mouth    tics    in    childhood, 

commenced  at  the  age  of  fifteen  to  advance  her  right  leg  involuntarily 

a  sort  of  tic  which  lasted  several  months  and  gave  place  to  paralysis 
of  the  same  limb  ;  for  this  affection  was  next  substituted  a  whistling 
tic,  and  then  for  a  whole  year  she  used  from  time  to  time  to  give 
vent  to  a  loud  "Ah  !"  When  she  came  under  observation  she  was 
suffering  from  a  tic  of  salutation,  with  retrocollic  jerking  of  the  head 
and  shrugging  of  the  right  shoulder. 


One   of    our  own    patients   furnished   us  with   the 
following  story : 

The  disease  made  its  debut  by  a  blinking  tic  of  both  eyes,  whose 
origin  in  the  absence  of  any  visual  defect  remained  undetermined  ;  grimacing 
and  distortion  of  the  mouth  were  the  next  to  appear,  as  well  as  wrinkling 
of  the  nose  and  forehead,  twitching  of  the  eyebrows  and  contraction 
of  one  platysma,  sometimes  even  of  the  ear  muscles  and  the  entire  scalp. 
Then  ensued  up-and-down  tossing  of  the  head,  or  rotation  of  it  from 
right  to  left,  and,  later,  elevation  and  advancement  of  the  shoulders, 
with  restless  agitation  of  hands  and  arms.  A  former  trick  of  his  of 
biting  his  nails  is  quite  in  abeyance  at  present  ;  instead,  he  catches  hold 
of  his  under  lip  every  moment  and  abrades  its  mucous  membrane  with 
his  nails,  so  much  so  that  the  lip  is  swollen  and  cracked  like  those  of 
children  with  nibbling  tics.  Some  months  ago  he  acquired  the  habit 
of  giving  utterance  to  a  soft  little  cry  not  unlike  the  sound  made  by 
a  guinea-pig. 

One  tic  has  succeeded  another  in  an  unbroken  series.  The  facial 
tics  were  more  of  the  nature  of  grimaces,  which  the  child  amused  itself 
in  repeating;  no  doubt  the  scratching  of  the  lip  was  a  sequel  to  the 
desire  of  experiencing  a  new  sensation,  while  the  movements  of  hands, 
arms,  and  shoulders  were  very  variable  and  different  enough  from  the 
accompanying  phenomena.  No  one  of  the  tics  was  at  all  of  protracted 
duration  ;  on  the  contrary,  each  was  fugitive  and  changeable,  and  therein 
presented  a  resemblance  to  the  child's  mental  status.  In  sleep  they 
completely  disappeared  ;  in  the  presence  of  strangers  or  if  his  interest 
was  in  any  way  aroused,  they  quieted  down,  while  they  increased  on 
holidays,  during  games,  or  with  physical  fatigue. 

It  is  clear  that  determination  of  the  tic's  localisation 
and  mode  can  come  only  with  the  mental  evolution  of  the 
patient,  and  that  the  transformation  from  the  psychical 


STUDY  OF  THE  MOTOR  REACTION     133 

inconsistency  of  childhood  to  the  stability  of  the  adult 
is  paralleled  by  the  change  in  the  tic's  manifestations  as 
the  scale  of  age  is  ascended.  Any  individual,  whatever 
his  years,  who  is  in  the  stage  of  mental  infantilism,  will 
tic  after  the  manner  of  a  child,  for  the  characters  of  a 
tic  are  dependent  on  the  state  of  mind  of  its  subject. 


CHAPTER  VIII 

ACCESSORY   SYMPTOMS 

REFLEXES 

question  whether  in  cases  of  tic  there  is  any 
J-     alteration  in  superficial  or  deep  reflexes  can  be 
decisively  answered  only  by  an  appeal  to  statistics,  the 
information  afforded  by  which  has   hitherto  been   too 
scanty   and  too   incomplete.     Judging   from   our   own 
observations  in  about  thirty  cases,  we  feel   compelled 
to   admit  that   disorders    of   this   kind   are    altogether 
exceptional.     Careful    and    repeated    examination    has 
convinced   us   that   in  patients  suffering   from   tic   the 
knee,  ankle,  wrist,  elbow,  and  other  jerks,  the  plantar 
and  fascia  lata  reflexes,  as  well  as  those  of  the  pharynx, 
eyes,   etc.,    are    all   but   universally   normal,   and    any 
trifling  exaggeration  or  diminution  not  only  varies  from 
day  to  day,  but  also  in  no  wise  exceeds  the  differences 
met  with  in  health,  and  is  therefore  symptomatologically 
negligible.     In  the  manifold  varieties  of  tic  represented 
by  B.,  S.,  P.,  N.,  M.,  B.,  etc.,  whose  cases  are  quoted  here 
in    part,   our    inquiries    have    always    been    negative. 
Noir's  research  on  the  state  of  the  reflexes  in  idiocy 
complicated  with  tics  failed  to  expose  any  abnormality, 
and    even  where  the   knee    jerks  were   increased    no 
departure  from  the  usual  manifestations  of  the  tic  was 
discoverable.     It  is   of   course  permissible  to   suppose 
that  a  combination  of  the  latter  with  organic  disease 
of  the  nervous  system  might  explain  the  modification  of 

134 


ACCESSORY  SYMPTOMS  135 

the  reflexes.  In  this  connection  it  may  be  remembered 
that  on  one  occasion  we  found  the  customary  diminu- 
tion of  O.'s  knee  jerks  had  passed  into  actual  loss, 
and  although  on  the  next  day  they  were  present 
again,  the  occurrence  was  suspicious  enough  to  justify 
one  in  entertaining  the  idea  of  incipient  tabes.  Even 
if  the  existence  of  other  signs  had  corroborated  this 
diagnosis,  the  incontestable  genuineness  of  O.'s  tics 
would  have  remained,  so  that  the  attempt  to  correlate 
the  derangement  of  the  reflexes  with  the  existence  of 
tics  is  somewhat  questionable. 

We  have  enjoyed  the  co-operation  of  M.  Babinski 
in  the  examination  of  one  of  our  patients,  L.,  in  whom 
we  were  able  to  determine  a  definite  and  symmetrical 
exaggeration  of  the  patellar  reflexes,  a  slight  increase 
in  the  right  triceps  jerk,  and,  in  making  the  subject  rise 
from  a  prone  to  a  sitting  position  with  the  arms  folded, 
a  very  minor  degree  of  flexion  of  the  thigh  on  the 
trunk. 

The  first  of  these  symptoms  is  of  no  pathognomonic 
value,  and  while  the  others  no  doubt  are  characteristic 
of  organic  disease,  their  development  in  this  instance 
is  too  imperfect  to  warrant  the  deduction  of  pyramidal 
involvement.  For  the  last  ten  years  L.'s  motor  control 
has  been  very  defective.  The  muscular  activity  of 
the  right  half  of  his  body  takes  the  form  of  irregular 
contractions,  badly  timed  and  inaccurate  in  range ; 
in  spite  of  the  absence  of  pain,  the  timidity  with  which 
they  are  executed  hinders  their  ever  attaining  a  normal 
amplitude ;  and  at  the  same  time  his  inability  to 
appreciate  the  direction  and  intensity  of  the  motor 
reaction,  the  outcome  of  excessive  muscular  vigilance, 
illustrates  a  certain  loss  of  the  sense  of  position  of 
his  limbs. 

The  existence  of  an  actual  irritative  lesion  is  there- 
fore problematical,  and  it  is  scarcely  conceivable  that 


136         TICS  AND    THEIR    TREATMENT 

organic  mischief  of  ten  years'  duration  could  have 
produced  these  clinical  symptoms  without  creating 
graver  disturbance  of  the  reflexes,  or  effecting  changes 
of  a  trophic  nature  in  muscular  and  other  tissues. 

From  the  pathogenic  and  diagnostic  point  of  view, 
the  detection  of  conspicuous  and  persistent  alterations 
in  the  reflexes  is  of  deep  significance.  It  is  an  im- 
portant factor  in  the  differentiation  between  tic  and 
spasm. 

Sometimes  the  task  is  unusually  arduous,  as  when 
the  unilateral  distribution  of  the  motor  troubles  recalls 
the  clinical  picture  of  lesions  of  the  pyramidal  paths. 
In  L.,  for  instance,  the  hemichorea  and  the  torticollis 
were  on  the  right  side,  and  in  a  case  published  by 
Desterac  a  similar  condition  obtained,  the  writers' 
cramp,  hip  spasm,  and  head  rotation  being  all  confined 
to  the  right.  Notwithstanding  the  fact  that  this  patient 
had  exaggerated  knee  jerks,  ankle  clonus,  and  a  double 
extensor  response,  an  opportunity  for  examination 
given  to  one  of  us  made  it  clear  that  the  untimely 
movements  and  bizarre  attitudes  were  similar  to  what 
has  been  noted  in  certain  cases  of  tic. 

At  the  Neurological  Society  of  Paris  a  case  was 
shown  by  Babinski l  of  left  spasmodic  torticollis,  with 
marked  spasms  of  the  left  arm  and  left  leg,  and  a 
homolateral  extensor  response,  and  it  was  contended 
that  if  one  and  the  same  cause  underlay  these 
phenomena — nor  did  there  appear  any  adequate  reason 
to  doubt  it — and  if  the  reversal  of  the  plantar  reflex 
was,  conformably  to  received  opinion,  to  be  interpreted 
as  indicating  a  derangement  in  the  function  of  the 
pyramidal  system,  then  it  was  allowable  to  attribute 
the  muscular  spasms  to  the  same  derangement,  in 
which  circumstances  the  natural  conclusion  was  that 

1  BABINSKI,   "  Sur  un  cas  d'h6mispasme  (contribution  a  1'dtude  du 
torticolis  spasmodique),''  Rev.  neurologique,  1900,  p.  142. 


ACCESSORY  SYMPTOMS  137 

spasmodic  torticollis  itself  might  sometimes  at  least 
be  dependent  on  pyramidal  irritation  of  an  as  yet 
undetermined  kind. 

More  recently  still,  another  patient  was  exhibited 
by  the  same  observer,1  in  whom  the  association  of  head 
rotation  and  convulsions  of  the  arm  on  the  left,  with 
increase  of  the  triceps  reflex,  was  conceivably  the  out- 
come of  pathological  stimulation  of  the  pyramidal  tract. 
Yet  the  symptoms  in  each  of  these  cases  were  curiously 
analogous  to  what  we  find  in  mental  torticollis,  in 
which  abnormalities  of  the  reflexes  are  conspicuous  by 
their  absence.  We  ought  not  on  that  account  to 
reject  the  hypothesis  of  concurrent  organic  disease, 
inasmuch  as  a  structural  modification  may  be  no  longer 
the  cause  but  the  consequence  of  inordinate  repetition 
of  a  motor  reaction.  Muscular  hypertrophy  or  atrophy 
may  be  the  sequel  to  tics  born  of  ideas  that  find  motor 
expression,  and  circulatory  and  even  cellular  changes 
may  ensue  on  gesticulatory  excess.  The  objective  signs 
that  reveal  the  existence  of  a  point  of  irritation,  on  the 
presence  of  which  the  diagnosis  of  spasm  depends,  are 
commonly  so  trivial  as  to  be  wellnigh  valueless,  and 
should  they  be  awanting,  the  motor  disturbance  appears- 
to  be  purely  functional,  and  may  be  considered  a  tic. 
At  the  same  time  we  must  admit  the  possibility  of 
mixed  forms,  where  the  functional  element  is  linked 
with  primary  or  secondary  organic  disease,  and  perhaps 
their  occurrence  is  more  general  than  is  ordinarily 
imagined.  We  repeat,  however,  that  rigorous  and 
lengthy  investigation  alike  of  the  psychical  and  the 
somatic  phases  of  the  condition,  embracing  the  state  of 
the  reflexes,  will  usually  furnish  sufficient  information  to 
facilitate  the  question  of  diagnosis  and  justify  a  positive 
statement. 

1  BABINSKI,  "Sur  le  spasme  du  cou,"  Rev.  neurologique,  1901,  p.  693. 


138          TfCS  AND    THEIR    TREATMENT 

ELECTRICAL  REACTIONS 

The  examination  of  the  electrical  reactions  of  the 
muscles  concerned  in  a  tic  is  a  clinical  method  seldom, 
if  ever,  resorted  to,  and  we  can  scarcely  expect  it  to 
yield  decisive  results  from  the  symptomatological 
aspect.  As  with  the  reflexes,  it  may  happen  that  we 
cannot  afford  to  neglect  its  diagnostic  significance  in 
certain  cases.  For  example,  we  have  had  occasion  to 
test  its  worth  in  studying  the  case  of  young  J.,  whose 
trouble  consisted  in  a  clonic  tic  of  elevation  of  the  left 
shoulder,  and  a  tonic  attitude  tic  of  the  left  arm 
whereby  it  was  firmly  applied  against  the  body.  No 
important  alteration  in  electrical  contractility  was  dis- 
covered, although  the  response  in  the  upper  part  of  the 
left  trapezius — which,  by  the  way,  was  more  voluminous 
than  on  the  right — was  brisker  than  in  its  fellow.  On 
the  other  hand,  the  right  deltoid,  sternomastoid,  and 
pectoral,  were  more  excitable  than  on  the  left. 

Here,  of  course,  the  evidence  supplied  by  electrical 
examination  only  served  to  confirm  the  knowledge 
gathered  from  other  clinical  sources. 

VASOMOTOR  AND  SECRETORY  AFFECTIONS 

Disorders  of  the  vasomotor  system  rarely  fail  to 
assert  themselves  in  the  subjects  of  tic,  but  they  do 
not  in  any  wise  differ  from  such  as  are  met  with  in 
the  majority  of  "  nervous "  individuals.  The  average 
sufferer  from  tic  is  emotional,  and  apt  to  betray  his 
emotion  by  blushing  for  the  most  childish  reason.  This 
symptom  may  be  in  itself  trifling  enough,  yet  it  may 
afford  the  earliest  indication  of  mental  instability  the 
nature  and  extent  of  which  subsequent  research  will 
determine.  It  is  even  conceivable  that  fear  of  blushing 
— the  ereutophobia  of  Regis — may  be  at  the  bottom  of 


ACCESSORY  SYMPTOMS  139 

certain  gestures  intended  to  conceal  the  heightened 
colour  the  apparition  of  which  is  so  humiliating.  The 
form  they  assume  is  generally  a  movement  of  the  arm 
or  hand  over  the  face,  to  mask  the  momentary  dis- 
comfort, and  while  in  most  instances  they  are  no  more 
than  stereotyped  acts,  they  may  develop  into  full-blown 
tics. 

In  regard  to  secretory  affections,  we  have  frequently 
observed  the  concurrence  of  hyperidrosis  and  emotional 
phenomena  in  those  who  tic.  Young  J.,  S.,  P., 
are  cases  in  point.  The  slightest  exertion,  the  least 
effort  of  attention,  are  followed  by  an  extraordinary 
secretion  of  sweat,  entailing  constant  carrying  of  a 
handkerchief  in  the  hand,  and  ceaseless  mopping  of 
the  forehead  or  temples.  This  performance  becomes 
stereotyped,  and  is  gone  through  even  when  there 
is  no  perspiration  at  all.  Suppression  of  the  hand- 
kerchief sometimes  causes  actual  malaise,  but  this 
injunction  must  never  be  forgotten  if  a  cure  is  to  be 
effected. 

[Persons  afflicted  with  tic  often  develop  a  sort  of 
visceral  instability  which  betrays  itself  in  indigestion, 
dyspepsia,  constipation,  diarrhoea,  and  in  every  variety 
of  dietetic  and  alimentary  caprice. 

It  is  rare  to  meet  with  troubles  of  micturition, 
nocturnal  enuresis  scarcely  deserving  mention  owing 
to  its  frequency  among  all  young  degenerates  and  to 
its  being  so  commonly  the  outcome  of  neglect. 
Oppenheim,1  however,  considers  diurnal  enuresis  worth 
including  in  the  symptomatology,  and  Brissaud2  has 
described  polyuria  and  pollakiuria  in  association  with 
obsessional  preoccupation.  These  are  really  functional 
disturbances  in  which  increased  desire  is  followed  by 

1  OPPENHEIM,  Medecinskoc  Obosrenje,  1901. 

3  BRISSAUD,  "  La  polyurie  des  deg6n6r6s,"  Presse  med.t  April, 
1897. 


140         TICS  AND   THEIR   TREATMENT 

increased  vesical  action,  and  may  be  regarded,  if   one 
likes,  as  micturition  or  sphincter  tics.1] 


AFFECTIONS  OF  SENSATION 

Generally  speaking,  objective  disturbances  of  sensi- 
bility do  not  occur,  and  while  subjective  changes  are 
more  frequent,  they  may  be  entirely  lacking  even  in 
long-standing  and  aggravated  cases.  What  the  patients 
usually  complain  of  is  a  more  or  less  persistent,  dis- 
agreeable, uncomfortable  sensation,  rarely  described 
as  painful,  and  often  compared  with  a  feeling  of 
stiffness  or  fatigue.  Or,  again,  they  may  be  conscious 
of  a  sense  of  constriction  or  of  dragging  in  the  affected 
muscles,  either  at  their  insertions  or  in  the  muscle  belly, 
or  sometimes  in  the  joints  concerned.  These  subjective 
sensations  are  characterised  by  extreme  variability  in 
time  and  in  degree.  Moreover,  the  accounts  given  by 
patients  of  their  own  sufferings  ought  to  be  accepted 
with  reserve.  Not  merely  are  they  ready  to  exaggerate 
and  incapable  of  accurately  depicting  and  localising 
their  sensations,  but  they  also  exhibit  a  curious  tendency 
to  false  interpretation :  they  attribute  an  erroneous 
pathological  significance  to  their  feelings,  and  proceed 
to  elaborate  a  thousand  ridiculous  variations,  thereby 
inviting  in  a  sense  the  eruption  of  fresh  tics.  In  all 
this  behaviour  their  mental  imperfections  are  abundantly 
manifest. 

We  may  remind  ourselves  in  this  connection  how 
O.'s  various  inventions  had  no  other  effect  than 
that  of  provoking  new  tics,  and  another  illustration 
is  to  hand  in  the  case  of  S.,  an  account  of  whose 
mental  torticollis  will  be  found  in  a  previous  chapter. 

1  MEIGE,  "  Neue  Beitrage  zur  Prognose  und  Behandlung  der  Tics," 
Journ.f.  Neurolog.  u.  Psychiat.,  Bd.  1 1,  Hft.  2-3  ;  "  Tics  des  sphincters," 
Congres  df  Rennes,  1905. 


ACCESSORY  SYMPTOMS  141 

Any  trifling  item  of  passing  interest  used  to  make  S.  forget 
altogether  the  more  or  less  acute  pain  he  experienced  in  his  neck  and 
shoulders,  and  reacted  no  less  successfully  on  his  torticollis.  When 
systematic  and  methodical  exercise  of  the  muscles  was  ordered,  nothing 
was  more  natural  than  that  their  long  period  of  inactivity  should  have 
the  result  of  causing  a  vague  feeling  of  stiffness  in  them  with  the  unwonted 
action.  Yet  S.  never  dreamed  of  such  an  ordinary  explanation,  but 
pessimistically  exaggerated  the  sensation,  and  deemed  it  an  infallible  sign 
of  the  spread  of  the  disease.  It  proved  to  be  a  simple  enough  matter, 
however,  to  convince  him  of  its  harmlessness,  for  it  was  sufficient  to 
remind  him  of  the  corresponding  stiffness  he  had  felt  after  his  first 
attempts  at  riding  and  fencing,  and  from  that  moment  he  ceased  to  pay 
any  attention  to  it  and  therefore  to  complain. 

"With  spasm,  on  the  other  hand,  pain  is  more 
frequently,  though  not  always,  associated.  It  may  be 
said,  of  course,  that  since  a  tic  may  be  evolved  from 
a  spasm,  the  pain  of  the  latter  is  really  the  exciting 
cause  of  the  former,  but  in  the  tic  as  it  is  constituted 
all  these  initial  disturbances  have  disappeared,  and  what 
the  patient  does  feel  is  the  consequence  of  excess  of 
muscular  action  or  of  articular  displacement.  His 
dolorous  sensations  form  the  sequel,  .not  the  prelude  ; 
they  are  not  symptoms,  but,  so  to  speak,  complications. 


CHAPTER  IX 

THE   DIFFERENT    TICS 

THIS  chapter  we  shall  devote  to  a  review,  necessarily 
incomplete,  of  the  principal  sites  in  which  tics 
are  to  be  met -i with.  We  do  not  pretend  to  have 
collated  every  known  case  observed  up  to  the  present, 
and  we  foresee  the  likelihood,  moreover,  of  new  tics 
coming  into  being.  Their  numbers  are  as  unlimited 
as  is  the  diversity  of  functional  acts  of  which  they 
form  the  pathological  expression.  We  must  content 
ourselves,  then,  with  the  consideration  of  the  most 
familiar  and  most  recent  examples. 

A  rational  classification  would  entail  discussion  of 
the  various  modes  of  derangement  to  which  functional 
acts  are  liable,  and  this  would  demand  in  its  turn  a 
preliminary  tabulation  of  function.  How  onerous  such 
a  task  is,  is  patent  from  the  uniform  imperfection  of 
the  attempts  already  made,  and  the  equivocal  nature 
of  their  conclusions. 

We  have  studiously  avoided  the  designation  of  a 
tic  by  the  muscle  or  muscles  that  determine  it.  To 
specify  the  precise  muscle  involved  is  sometimes 
attended  with  no  little  difficulty,  while  if  several,  as 
is  customary,  are  concerned,  their  association  is  rarely 
anatomical;  indeed,  this  is  one  of  the  chief  aids  to 
diagnosis  between  tics  and  spasms.  Should  the  con- 
vulsion chance  to  follow  an  anatomical  distribution, 
neighbouring  muscles  are  apt  to  participate  as  well. 
Hence  it  is  advisable  to  name  a  tic  after  its  morpho- 

142 


THE  DIFFERENT   TICS  143 

logical   situation,  or,   better   still,  from   the   functional 
act  of  which  it  is,  in  Charcot's  phrase,  the  caricature. 

This  is  the  plan  we  shall  pursue  in  our  successive 
examination  of  the  different  parts  of  the  body  disposed 
to  be  the  seat  of  tics. 


FACIAL  TICS-TICS  OF  MIMICRY 

Of  all  tics,  those  of  the  face  are  the  most  frequent, 
and  the  most  easy  to  see.  No  other  part  is  as  rich 
in  muscles  whose  functions  are  so  diversified — nictitation, 
mastication,  suction,  respiration,  articulation,  etc.  More- 
over, the  face  is  the  abode  of  the  mimic  expressions, 
each  one  of  which  is  the  revelation,  by  muscular  play, 
of  some  sentiment,  or  passion,  or  emotion.  Hence  the 
idea  has  been  entertained  of  adopting  a  physiological 
classification.  In  the  smiling  tic  of  Bechterew,  for  an 
instance,  the  muscular  contractions  are  framed  into 
a  smile  in  the  absence  of  any  provocative  to  mirth ;  in 
a  similar  fashion,  the  sniffing  tic  brings  to  mind  the 
inhaling  performances  of  snuff-takers. 

Facial  tic  is  frequently  unilateral.  It  is  rare  to  find 
the  whole  muscular  distribution  of  one  facial  nerve 
involved,  however,  this  being  a  property  rather  of 
spasm,  as  is  also  the  restriction  to  a  particular  branch. 
A  common  event  is  the  simultaneous  abstention  of 
some  facial  muscles  and  implication  of  others  belonging 
to  a  different  nerve  supply. 

If  the  condition  is  bilateral,  as  a  general  rule  only 
those  muscles  on  each  side  co-operate  that  are  wont  to 
act  in  concert  for  the  accomplishment  of  some  function. 
In  a  case  reported  as  bilateral  facial  spasm  by  Glaus 
and  Sano,1  in  which  both  sides  of  the  face  and  neck 
were  affected,  the  exaggeration  of  the  convulsions 

1  CLAUS  AND  SANO,  "  Spasme  bilateral  de  la  face  et  du  cou," 
Journ.  de  neurologte,  1899. 


144         TICS  AND    THEIR    TREATMENT 

by  emotion,  their  curtailment  during  rest  and  dis- 
appearance in  sleep,  coupled  with  the  fact  of  their 
temporary  arrest  by  recourse  to  subterfuge,  suggest 
that  the  condition  is  really  one  of  tic. 

The  contractions  of  the  facial  muscles  are  usually 
associated  to  produce  a  more  or  less  complex  grimace. 
Movements  of  forehead,  eye,  nose,  or  mouth,  may 
succeed  each  other  or  be  superimposed  one  on  the 
other  without  any  preconceived  order,  or  the  tic  may 
consist  in  the  synchronous  activity  of  two  or  more 
muscles. 

Of  course  any  and  every  facial  tic  may  occur  by 
itself,  but  careful  investigation  will  often  reveal  con- 
comitant reactions  of  other  muscular  groups.  The 
sniff  that  accompanies  puckering  of  the  nose  indicates 
the  engagement  of  the  muscles  of  inspiration. 

Facial  tic,  moreover,  may  be  tonic  as  well  as 
clonic,  instances  in  point  being  closure  of  the  eyelids, 
wrinkling  of  the  forehead,  twisting  of  the  nose, 
distortion  of  the  mouth,  etc.,  of  longer  or  shorter 
duration. 

Any  of  the  facial  muscles  may  be  attacked  by  tics. 
These  commonly  furnish  an  illustration  of  functional 
disturbance  of  mimicry,  as  in  Oppenheim's  cases  of  tic 
limited  to  the  frontales,  whereby  astonishment  or  dis- 
may was  expressed,  or  in  contraction  of  the  superciliary 
muscles,  which  conveys  a  look  of  pain  or  of  mournful- 
ness.  Spread  to  the  scalp  muscles  may  take  place, 
causing  a  perpetual  to-and-fro  movement  of  the  hair, 
of  which  0.  and  Miss  R.  supply  examples.  The 
platysma  is  sometimes  the  seat  of  a  tic.  One  of  Oppen- 
heim's patients  was  a  child  with  alternating  twitches  of 
his  two  platysmas ;  it  is  of  interest  to  note  he  was 
able  to  contract  either  voluntarily.  This  condition  is 
generally  associated  with  similar  contractions  in  other 
facial  muscles,  as  in  a  case  of  facial  and  palpebral  tic 


THE  DIFFERENT   TICS  145 

with  platysma  involvement  recorded  by  Meirowitz,1  or 
as  in  young  M. 

A  not  infrequent  accompaniment  is  a  shrug  of  one 
or  both  shoulders,  due  to  synergic  contraction  of  the 
trapezius.  The  resulting  complex  may  be  considered 
an  act  of  mimicry  in  so  far  as  it  is  an  expression  of 
disdain. 

TICS    OF   THE    EAR— AUDITORY    TICS 

The  muscles  of  the  external  ear  come  often  into 
play.  One  of  our  patients  had  a  tic  of  the  left  ear, 
consisting  in  visible  elevation  of  the  pinna.  A  case  of 
tic  of  the  ear  muscles  has  been  described  by  Romberg, 
and  another  by  Bernhardt,  in  the  distribution  of  the 
occipital  and  posterior  auricular  nerves.  Reference  is 
made  by  Seeligmiiller 2  to  a  ten-year-old  girl  suffering 
from  unceasing  involuntary  contractions  of  the  eyelids 
and  of  various  head  and  neck  muscles,  with  wrinkling 
of  the  forehead  and  movements  of  the  ears.  His  original 
diagnosis  of  chorea  was  discredited  by  his  subsequently 
learning  that  the  child,  in  common  with  a  younger  sister 
and  a  brother,  had  for  several  years  been  exercising 
herself  by  making  faces,  and  in  particular  by  attempting 
to  move  her  ears. 

It  is  quite  conceivable  that  certain  middle-ear 
phenomena  are  comparable  to  the  tics.  0.  used  often 
to  complain  of  hearing  noises  in  his  right  ear,  which 
came  and  went  with  his  tics  of  face  and  neck.  Now,  it 
is  well  known  that  the  probable  explanation  of  the 
humming  sound  attending  forcible  closure  of  the 
orbiculares  palpebrarum  is  the  variation  in  labyrinthine 
tension  due  to  the  synergic  contraction  of  the  stapedius. 

1  MEIROWITZ,  "A  Case  of  Habit-spasm,"  The  Post-graduate,  1900, 
p.  643. 

J  SEELIGMULLER,  "  Zur  Pathogenese  der  peripheren  Krampfe," 
St.  Petersburger  med.  Wochenschrift,  1881,  No.  2,  p.  13. 

1O 


H6         TICS  AND   THEIR   TREATMENT 

This  absolutely  normal  effect  may  be  exaggerated  by 
predisposed  and  preoccupied  individuals  into  a  sort  of 
auditory  tic. 


TICS    OF    THE    EYES-NICTITATION    AND    VISION    TICS 

For  the  sake  of  precision,  tics  of  the  eyes  may  be 
subdivided  into  eyelid  tics  and  eyeball  tics. 

A.  Eyelid  Tics.— These,  perhaps  the  commonest  of 
all  tics,  may  be  either  unilateral  or  bilateral.  They 
consist  simply  in  a  palpitation  of  the  upper  lid,  repeated 
at  irregular  intervals,  and  differing  from  ordinary 
blinking  only  in  augmented  frequency  and  abruptness. 
The  form  they  usually  assume  is  that  of  a  wink,  attri- 
butable in  the  first  instance  to  contraction  of  the 
orbicularis,  but  supplemented  by  the  zygomatics  and 
muscles  of  the  nose. 

The  tonic  variety  of  the  same  tic  is  constituted  by  a 
contraction  of  inordinate  length,  the  outcome  of  which 
is  the  all  but  permanent  maintenance  of  the  eye  in  a 
half-closed  position.  The  suspension  of  this  tonic  tic 
by  volitional  effort  accentuates  its  distinction  from  con- 
tracture.  In  one  of  our  patients  a  tic  of  this  nature, 
which  gave  a  singularly  sleepy  cast  to  the  features, 
was  easily  relieved  by  suitable  gymnastic  treatment. 
The  converse  condition  obtained  in  another  case,  where 
excessive  gaping  of  the  palpebral  fissure  contributed 
an  unwonted  fixity  to  the  expression,  which  simultaneous 
contraction  of  the  corrugator  supercilii  served  to 
heighten  into  one  of  wild  anger.  These  two  tics  cor- 
responded to  two  diametrically  opposed  traits  in  their 
subject's  character — viz.  nonchalance  and  impatience 
respectively,  and  it  is  interesting  to  recall  in  this 
connection  how  the  varying  moods  depend  for  their 
physiognomical  delineation  chiefly  on  the  degree  of 
curvature  of  the  palpebral  arc. 


THE  DIFFERENT   TICS  14? 

Valleix,1  who  employed  the  term  "idiopathic  facial 
convulsion"  to  designate  tic,  cites  a  case  where  even 
in  moments  of  tranquillity  the  left  eye  seemed  slightly 
smaller  than  its  fellow,  by  reason  of  a  feeble  contraction 
of  the  orbicularis.  Persistent  grimaces  of  this  kind 
resemble  tics  of  attitude  and  stereotyped  acts,  and  the 
possibility  of  their  occurrence  must  not  be  overlooked, 
once  the  diagnosis  of  facial  paralysis  or  spasm  has  been 
rigorously  excluded. 

The  terms  blepharospasm  and  blepharoclonus,  some- 
times applied  to  tonic  and  to  clonic  involuntary 
palpebral  contractions  respectively,  ought  to  be  strictly 
reserved  for  spasms  and  contractures  properly  so  called. 
For  example,  von  Graefe's  case  of  blindness  consequent 
on  permanent  closure  of  the  eyelids  in  a  child  is  un- 
doubtedly one  of  blepharospasm.  No  tic  could  have 
been  attended  with  such  a  result,  whereas  compression 
of  branches  of  the  trigeminal  at  their  points  of  exit 
might  determine  reflex  tonic  contraction  of  the  orbi- 
cularis, and  so,  for  that  matter,  might  a  central  lesion. 
Hence  in  these  circumstances  it  is  correct  to  use  the 
word  spasm. 

Palpebral  tics  are  among  those  that  ordinarily  begin 
by  a  spasmodic  reaction  to  an  extraneous  source  of 
irritation,  such  as  that  yielded  by  a  foreign  body,  a 
speck  of  dust,  an  eyelash,  or  by  any  form  of  conjunctival 
inflammation. 

Eyelid  tics  (says  Parinaud  *)  are  known  to  ophthalmologists  as  clonic 
blepharospasms.  Their  starting-point  is  always  some  peripheral  stimulus, 
in  particular  an  everyday  variety  of  conjunctivitis  characterised  by  the 
presence  of  granulations  in  the  lower  part  of  the  sac.  To  discover  these 
granulations  it  may  be  necessary  to  explore  the  internal  aspect  of  the 
lid.  In  my  opinion,  they  are  a  prolific  cause  of  tic,  especially  in  young 
children,  and  their  removal  effects  a  cure  in  the  vast  majority  of 
cases. 

1  VALLEIX,  Guide  du  medecin  praticien,  1853,  vol.  iv.  p.  617. 
*  PARINAUD,  Soc.  de  tteur.  de  Paris,  April  18,  1901. 


148         TICS  AND   THEIR    TREATMENT 

It  is  only  when  the  blinking  abides  in  spite  of  the 
suppression  of  the  exciting  cause  that  it  can  be  com- 
prised in  the  category  of  tics,  otherwise  the  fact  of 
its  being  contingent  on  the  continuance  of  the  irritation 
shows  it  is  a  spasm. 

A  bright  light  sometimes  suffices  to  initiate  these 
conditions.  During  a  course  of  sittings  for  her  portrait, 
G.,  a  little  girl  eleven  years  of  age,  acquired  the  habit 
of  drooping  one  eyelid  slightly  to  shield  the  eye  from 
the  somewhat  glaring  light  of  the  studio,  but  the  per- 
sistence of  this  movement  in  other  surroundings  was 
evidence  of  its  degeneration  into  a  tonic  tic. 

Noir  quotes  the  case  of  one  of  his  colleagues  who 
was  for  a  long  time  inconvenienced  by  a  most  disagree- 
able blinking,  which  he  held  to  be  a  tic ;  but  a  simple 
explanation  was  forthcoming  in  the  unusual  length  of 
some  of  the  eyelashes  on  the  outer  part  of  the  upper 
lid  having  caused  their  entanglement  with  others  in 
the  under  one,  and  when  they  were  cut  off  the  spasm 
disappeared. 

In  the  following  instance,  reported  by  Toby  Cohn,1 
the  diagnosis  remains  undetermined : 

The  protracted  use  of  a  magnifying  glass  in  the  left  eye  was  the  means, 
in  a  watchmaker,  of  inducing  occasional  localised  twitches  of  the 
orbicularis,  which  were  not  slow,  however,  in  spreading  to  the  whole  of 
the  left  half  of  the  face.  They  may  at  first  have  been  an  involuntary 
motor  response  to  nipping  of  palpebral  twigs  of  the  trigeminal,  but  at 
a  later  period  their  independence  was  constant  and  pronounced.  With 
certain  associated  movements  such  as  articulation  or  deglutition,  or  during 
the  act  of  wiping  the  nose  or  shutting  the  eyes,  the  form  they  assumed 
was  tonic.  There  were  neither  subjective  nor  objective  sensory  phenomena 
to  note. 

We  have  recently  had  the  opportunity  of  observing 
a  genuine  case  of  eyelid  tic,  of  obscure  origin  perhaps, 

1  TOBY  COHN,  "Facialistic  als  Beschaftigungsneurose,"  Neur. 
Cenlralb.,  1897,  p.  21. 


THE  DIFFERENT   TICS  149 

but  one  whose  clinical  features  eliminate  the  hypothesis 
of  spasm. 

Brif.,  a  metal  polisher,  forty-seven  years  old,  came  on  March  10, 
1902,  to  Professor  Brissaud's  clinic  at  the  H6tel  Dieu,  conplaining  of 
involuntary  closure  of  the  eyes,  especially  when  out  walking.  In  his 
family  and  in  his  personal  antecedents  there  was  little  or  no  neuropathic 
or  psychopathic  tendency.  The  sole  trouble  for  which  he  sought  advice 
was  this  spasmodic  shutting  of  his  eyes,  rare  enough  under  most  circum- 
stances, but  aggravated  instantly  by  a  walk  of  even  a  few  paces. 

The  onset  had  been  quite  insidious  eighteen  months  previously,  and 
at  the  first  the  average  frequency  was  scarcely  more  than  thrice  or  four 
times  daily.  Whenever  Brif.  passed  into  direct  sunlight  the  move- 
ment was  particularly  liable  to  occur.  As  long  as  he  remained  seated 
at  his  work  he  was  free  from  it,  while  he  had  but  to  rise  and  take  a  step 
or  two  for  it  to  reappear  and  forthwith  commence  to  repeat  itself.  At 
home  any  effort  engaging  his  attention  inhibited  the  tic,  nor  was  there  any 
sign  of  it  in  the  course  of  our  interrogation  and  examination  of  him. 

Even  when  he  was  on  his  feet,  the  incidence  of  the  act  was  not  always 
uniform  ;  if  promenading  with  his  wife  and  children,  or  fishing  along 
a  river  side,  or  running  to  catch  a  tram,  he  was  not  hampered  by  his 
affliction.  When  he  rose  in  the  morning,  it  made  its  appearance  ere  he 
could  reach  the  window  to  look  out.  During  his  journeys  to  and  from 
his  place  of  business,  he  was  generally  unable  to  moderate  the  spasmodic 
movements,  particularly  towards  evening,  whereas  his  professional  pursuits 
in  the  daytime,  and  any  occupation — such  as  reading  the  newspaper — 
when  at  home  again,  wholly  counteracted  the  inclination  to  tic. 

The  production  of  this  untimely  gesture  of  his  Brif.  was  disposed 
to  attribute  to  the  action  of  sun  or  wind,  though  he  acknowledged  the 
regularity  of  its  occurrence  irrespective  of  either.  In  its  actual  nature 
the  contraction  was  tonic  in  type  and  of  several  seconds'  duration,  so 
that  he  used  to  cover  some  yards  with  eyes  shut.  From  the  outset  the 
will  had  always  exercised  a  marked  influence  on  it,  so  much  so  that  on 
certain  days  and  for  a  certain  space  he  could  check  the  convulsion,  and 
even  when  it  was  prolonged  he  contrived  by  volitional  effort  to  open  his 
eyes  sufficiently  to  pilot  himself  in  avoiding  obstacles. 

Careful  search  by  the  ordinary  tests  at  the  Quinze-Vingts  hospital 
failed  to  reveal  any  abnormality  whatever  in  his  eyes.  On  our  part,  we 
satisfied  ourselves  that  there  was  no  restriction  of  the  visual  fields. 

As  far  as  his  mental  state  was  concerned,  its  chief 
peculiarity  was  a  somewhat  childish  turn  of  mind,  a 
soupfon  of  that  psychic  infantilism  so  common  in  the 


ISO         TICS  AND   THEIR    TREATMENT 

subjects  of  tic ;  in  addition,  he  was  of  an  emotional 
temperament,  and  prone  to  perspire  or  blush  for 
no  valid  reason.  He  was  further  a  victim  to  a  pre- 
mature baldness  which  was  hereditary  in  the  family, 
and  which  may  be  cited  as  a  physical  stigma  of 
degeneration. 

B.  Eyeball  Tics. — The  extrinsic  muscles  of  the  eye 
occasionally  participate  in  the  tics  we  have  just 
discussed.  Assiduous  observation  of  patients  suffering 
from  blinking  tics  will  enable  the  physician  now  and 
then  to  detect  movements  of  the  eyeball  behind  the 
lowered  upper  lid. 

In  the  case  of  F.,  for  instance,  with  each  tic  of 
the  lids  the  eyeballs  deviated  briskly  upwards  and  to 
the  left.  Similarly  Miss  R.  turned  her  head  from 
right  to  left  at  the  same  time  as  the  eye  moved  obliquely 
to  the  left  and  in  an  upward  direction.  A  patient 
mentioned  by  Otto  Lerch  x  used  to  open  and  shut  his 
eyes  while  rotating  the  eyeballs  and  throwing  the  head 
back.  Occasionally  he  inclined  his  trunk  to  one  or 
other  side,  accompanying  the  act  with  disagreeable 
little  grunts. 

The  eruption  of  these  tics  may  equally  be  attributed 
to  some  foreign  body  or  minute  conjunctival  granulation, 
as  was  the  case  with  a  small  child  of  ten  years  under 
our  care,  who,  in  spite  of  the  withdrawal  of  the  irritating 
particle,  acquired  the  trick  of  tickling  the  inner 
surface  of  his  upper  lid  by  rolling  his  eye  about  when- 
ever he  happened  to  blink.  The  delight  he  took  in 
this  trivial  manoauvre  led  to  its  mechanical  reiteration, 
and  was  the  means  eventually  of  its  developing  into 
a  tic  which  required  a  sufficiently  delicate  muscle 
exercise  and  drill  for  its  repression. 

Defects  in  the   visual  apparatus  sometimes  induce 
1  LERCH,  "Convulsive  Tics,"  American  Medicine,  November  2,  1901. 


THE  DIFFERENT  TICS  151 

abnormal  movements  and  attitudes  which  may  become 
tics  if  careful  examination  does  not  elicit  their  ex- 
planation. 

Tic  of  the  eyeball  is  generally  associated  with  other 
tics,  ocular  or  facial,  but  it  may  occur  alone  and  bear 
a  resemblance  to  nystagmus,  a  peculiarity  we  have 
noticed  in  a  patient  perfectly  free  from  any  cerebro- 
spinal  disease.  It  is  almost  always  bilateral,  but  in 
some  cases  of  unilateral  palpebral  tic  it  is  more  pro- 
nounced on  the  side  of  the  latter. 

Fixity  of  the  eyes  is  characteristic  of  tonic  tics  of 
the  extrinsic  ocular  muscles,  and  gives  a  somewhat 
haggard  or  maybe  merely  attentive  expression  to  the 
countenance.  Very  frequently  it  escapes  observation, 
and  indeed  cannot  be  considered  a  tic  unless  there 
be  an  incongruity  between  it  and  the  ideas  at  that 
moment  uppermost  in  the  patient's  mind. 

Reference  has  already  been  made  to  the  historic 
example  of  an  ocular  tic  in  the  person  of  Peter  the 
Great.  A  series  of  interesting  discussions  has  taken 
place  recently  at  the  Neurological  Society  of  Paris  in 
regard  to  the  question  of  a  tic  of  elevation  of  the 
eyes. 

The  patient,  who  had  come  to  consult  Professor  Marie  at  Bicetre 
in  December,  1899,  was  presented  to  the  Society  in  the  first  instance  by 
M.  Crouzon.1  He  entered  the  room  with  his  eyes  fixed  on  the  floor,  but 
in  a  few  seconds  they  had  resumed  their  normal  position  in  the  horizontal 
plane.  At  frequent  intervals  he  raised  them  upwards,  or  inclined  his  head 
so  as  to  bring  the  pupils  into  contact  with  the  upper  lids,  the  natural 
position  of  rest  of  the  globes  being  regained  by  a  voluntary  effort  after 
each  displacement.  When  interrogated,  he  complained  of  not  being 
able  to  distinguish  objects  in  an  area  of  his  visual  fields  limited  by  an 
imaginary  line  drawn  from  his  eyes  to  strike  the  ground  at  a  point  six 
feet  in  front  of  him  ;  otherwise  his  sight  was  excellent.  The  history  he 
gave  was  to  the  effect  that  five  months  previously,  in  the  enjoyment  of 
perfect  mental  and  physical  health,  he  had  had  a  sudden  stroke,  and  been 

1  CROUZON,  "Tic  d'6l6vation  des  yeux,"  Soc.  de  neur.  de  Paris, 
January  n,  1900. 


152          TICS  AND   THEIR    TREATMENT 

unconscious  for  seventeen  hours.  No  sinister  results  ensued  till  four  days 
later,  when  he  lost  his  vision,  began  to  articulate  very  indistinctly,  and 
failed  to  recognise  his  wife,  continuing  in  that  state  for  the  next  two 
months.  Gradual  recovery  of  speech  and  sight  then  commenced,  but 
the  habit  of  looking  upwards  persisted.  The  absence  of  injury  to  the 
visual  apparatus,  coupled  with  the  presence  of  admitted  psychical  disorders, 
decided  Crouzon  in  his  consideration  of  the  condition  as  a  functional 
disturbance  of  the  ocular  muscles  analogous  to  tic. 

In  this  connection  the  significant  observation  was  made  by  Joffroy  that 
in  the  recumbent  position  the  patient's  eyes  assumed  their  ordinary  place, 
suggesting  a  comparison  with  those  dolls  whose  eyes  open  or  close 
according  as  they  are  held  vertically  or  horizontally.  In  his  opinion,  the 
eye  mobility  negatived  any  idea  of  contracture  consequent  on  central 
lesions. 

A  few  months  later  the  same  patient  was  submitted  a  second  time  to 
the  Society,  on  this  occasion  by  M.  Babinski,1  who  declared  himself  in 
disagreement  with  the  hypothesis  of  M.  Crouzon.  In  all  cases  of  mental 
torticollis,  so  called,  the  contrary  movement  to  that  the  execution  of  which 
is  impelled  by  the  spasm  can  from  time  to  time  be  accomplished, 
whereas  in  the  case  under  discussion  downward  as  opposed  to  upward 
deviation  was  never  obtained.  Further,  the  acute  onset,  with  loss  of  con- 
sciousness, militates  strongly  against  the  tic  theory,  and  indicates  rather 
a  variety  of  paralysis  of  the  inferior  recti,  or  paralysis  of  conjugate 
downward  movement,  secondary  to  organic  disease  of  the  nervous  system. 
The  difficulty  experienced  by  the  patient  in  inducing  his  eyes  to  resume 
the  horizontal  position  after  once  elevating  them  is  explicable  on  the 
assumption  that  the  action  of  the  superior  recti  is  no  longer  controlled 
by  their  antagonists  the  inferior  recti,  the  former  passing  into  a  state  of 
temporary  spasm,  which  is,  however,  strictly  consecutive  to  the  paralysis 
of  the  latter. 

M.  Parinaud  expressed  himself  as  being  in  accord  with  M.  Babinski, 
and  recalled  certain  rare  forms  of  associated  ocular  palsies  occurring 
with  paralysis  of  convergence,  a  combination  manifest  in  the  subject  in 
question.  Curiously  enough,  in  these  cases  the  disturbance  of  function 
is  always  ushered  in  by  a  stroke,  which  justifies  the  belief  in  the  focal 
nature  of  the  lesion. 

On  the  other  hand,  it  was  noticed  by  M.  Ballet  that  the  range  and 
facility  of  downward  deviation  varied  inversely  with  the  attention  devoted 
to  the  patient  by  the  examiner. 

On  yet  a  third  occasion  this  identical  case  provided  a  subject  of 
discussion  at  the  Society,  after  being  under  the  observation  of  Professor 
Pierre  Marie  in  Bicetre. 

1  BABINSKI,  "  Sur  la  paralysie  du  mouvement  associe"  de  1'abaissement 
des  yeux,"  Soc.  de  neur.  de  Paris,  June  7,  1900. 


THE  DIFFERENT   TICS  153 

Professor  Marie 1  had  failed  to  satisfy  himself  of  the  paralytic  nature 
of  the  phenomenon,  and  demonstrated  the  ease  with  which  the  eyeballs 
moved  downwards  if  the  patient  was  made  to  hold  his  head  in  the 
position  of  maximum  extension,  while  in  the  attempt  to  look  at  his  feet 
— the  head  being  held  normally — they  were  forthwith  inclined  violently 
upwards,  and  were  so  maintained  for  thirty  or  forty  seconds.  The 
only  view  tenable  was  that  he  was  suffering  from  a  sort  of  neurosis  whose 
outward  expression  was  this  spasmodic  elevation  of  the  eyes.  Additional 
confirmation  of  the  accuracy  of  this  hypothesis  was  supplied  by  a 
consideration  of  the  circumstances  attending  the  commencement  of  the 
illness.  The  sudden  and  unexpected  apoplexy,  of  seventeen  hours' 
duration,  had  been  accompanied  neither  by  stertor  nor  by  relaxation 
of  sphincters,  and  had  been  followed  by  an  equally  sudden  return  to 
consciousness,  the  faculty  of  speech  and  the  desire  for  food  reasserting 
themselves  unexpectedly.  The  ensuing  three  or  four  weeks  the  patient 
had  spent  in  a  curious  delirious  state,  not  unlike  the  post-seizure  stage 
of  hysteria,  a  trace  of  which  remained  in  the  guise  of  certain  eccentricities 
of  mind.  The  difficulty  in  his  speech  bore  a  resemblance  to  hysterical 
stammering  ;  and,  finally,  his  visual  fields  were  concentrically  and  bilaterally 
restricted. 

Of  the  subsequent  history  of  the  case  some  information  was  forth- 
coming at  a  later  date,2  corroborating  the  opinion  originally  pro- 
pounded by  Professor  Marie.  Simultaneously  with  the  diminution  in 
intensity  of  the  ocular  spasm  there  had  been  grave  deterioration  of 
the  patient's  mental  level,  as  evidenced  by  the  development  of  ideas  of 
persecution. 

In  the  subjects  of  tic,  and  especially  in  cases  of  mental  torticollis,  we 
have  noted  an  analogous  symptom,  consisting  in  inability  to  look  down 
at  the  feet,  except  perhaps  by  the  aid  of  innumerable  contortions, 
in  contrast  to  the  consummate  ease  of  upward  glances.  By  making 
the  person  write  at  a  blackboard,  and  observing  his  action  according 
as  his  hand  is  above  or  below  a  horizontal  plane  through  his  eyes,  one 
can  soon  convince  oneself  of  the  reality  of  the  occurrence,  yet  search 
will  fail  to  discover  any  sign  of  ophthalmoplegia. 

Patients  of  this  class  evince  a  remarkable  aptitude  for  elevation 
movements,  and  the  trouble  they  experience  in  depressing  the  eyeballs 
is  not  of  necessity  to  be  construed  as  denoting  paralysis  of  the  depressors, 
but  rather  indicates  the  presence  of  a  tic  of  the  elevators,  as  Professor 
Marie  says — a  tic  born  of  a  habit,  and  nourished  perhaps  by  the  dread  such 
persons  feel  of  witnessing  an  exaggeration  of  their  convulsive  movements 
whenever  they  cast  their  eyes  down. 

1  MARIE,  "  Spasme  nSvropathique  d'6l6vation  des  yeux,"  Soc.  de 
neur.  de  Paris,  April  18,  1901. 

12  RAYMOND  AND  CESTAN,  Rev.  neurologique,  1902,  p.  52 


154         TICS  AND    THEIR    TREATMENT 

Our  object  in  summarising  this  discussion  has  been 
twofold :  at  once  to  note  the  existence  of  tics  of 
extrinsic  eye  muscles,  and  to  illustrate  the  intricacies 
of  their  diagnosis. 

A  case  not  unlike  the  preceding,  recorded  by  Nogues 
and  Sirol,1  was  characterised  by  inability  to  look  above 
a  certain  height  without  simultaneous  raising  of  the 
head.  Paralysis  of  the  associated  movements  of  eleva- 
tion was  excluded  by  the  fact  of  the  gradual  onset, 
without  an  ictus,  and  by  the  absence  of  paralysis  of 
convergence  and  of  impairment  of  speech  and  intellect. 
Basing  their  conception  of  the  case  upon  its  post-febrile 
origin  and  the  knowledge  of  hysterical  antecedents, 
the  authors  were  disposed  to  regard  it  as  a  neuropathic 
manifestation. 

It  is  conceivable  that  some  cases  of  strabismus  in 
children  are  nothing  more  than  vicious  habits  trans- 
formed into  tics,  since,  as  a  matter  of  fact,  attentive 
supervision  is  frequently  sufficient  to  effect  a  cure, 
although  no  doubt  in  other  cases  some  visual  abnormality 
is  responsible  for  the  condition. 

Finally,  since  accommodation  is  a  function  sub- 
servient to  the  will,  tics  of  accommodation  are 
theoretically  possible.  Our  information  thereanent  must 
be  sought  from  the  ophthalmologists.  We  have  met 
with  genuine  professional  cramps  of  accommodation  in 
those  who  use  the  microscope,  as  well  as  in  opticians, 
watchmakers,  etc. 


TICS    OF    THE    NOSE— SNIFFING    TICS 

The  form  these  tics  commonly  take  is  a  puckering 
of  the   nostrils  to  the  more  or   less  noisy  accompani- 

1  NOGUES  AND  SIROL,  "  Un  cas  de  paralysie  associde  des  muscles 
droits  supgrieurs  de  nature  hysterique,"  Soc.  de  neur.  de  Paris, 
March  7,  1901. 


THE   DIFFERENT   TICS  155 

ment  of  a  nasal  inspiration  or  expiration,  associated 
usually  with  curling  of  the  upper  lip.  They  are 
principally  the  sequel  to  some  coryza,  or  inflammation, 
or  some  little  nasal  fissure  or  furuncle,  and  in  their 
•essence  constitute  a  derangement  of  a  complex  functional 
act  intended  to  ensure  the  dislodgment  of  any  obstruc- 
tion in  the  respiratory  passages  of  the  nose,  in  which 
.act  the  muscles  of  inspiration  or  of  expiration  bilaterally 
co-operate.  Where  the  contraction  of  the  nose  muscles 
is  unilateral,  it  is  generally  part  and  parcel  of  a  facial 
grimace  confined  to  that  side,  and  therefore  an  anomaly 
•of  mimicry. 

As  for  the  pathogenic  mechanism  of  the  sniffing 
tic,  it  is  simple  enough.  Some  little  passing  obstacle  in 
the  air-ways,  some  minute,  irritating  sore,  supply  the 
occasion  for  an  expiratory  reaction,  in  the  first  instance, 
with  wrinkling  of  the  nose  and  dilatation  of  the  nostrils, 
the  repetition  of  which  with  each  fresh  sensation  of 
^discomfort  or  of  pain  speedily  becomes  automatic,  and 
persists  as  a  tic  when  mucus  or  abrasion  has  disappeared. 
Bo  far  from  being  obstinate,  these  tics  are  eminently 
.amenable  to  treatment  if  they  are  uncomplicated.  We 
have  remarked  on  their  occurrence,  by  the  way,  in  the 
-case  of  O.  and  his  sister,  in  young  J.,  in  G.,  in  the 
wife  of  S.,  etc. 

TICS   OF   THE    LIPS— SUCKING    TICS 

The  diversity  of  movement  of  which  the  buccal 
•orifice  is  capable  warrants  the  statement  that  the  tics 
-of  this  class  are  almost  too  numerous  for  detailed 
description.  At  times  only  the  orbicularis  oris  is 
involved,  unilaterally  or  bilaterally;  at  others,  con- 
comitant implication  of  the  elevators  and  depressors 
,of  the  lips,  or  of  the  chin  muscles  and  the  platysma, 
furnishes  the  basis  for  all  sorts  of  pouting,  biting,  and 


1 56         TICS  AND   THEIR   TREATMENT 

sucking  movements,  and  for  every  variety  of  smile 
and  grin.  Here  again  the  clonic  form  of  contraction 
is  the  most  habitual,  although  that  rapidity  and 
abruptness  which  we  commonly  identify  with  such 
contractions  may  not  always  be  conspicuous.  G-uinon 
says  of  a  young  patient  of  his,  at  one  time  addicted  to 
innumerable  tics,  that  the  relative  sluggishness  with 
which  she  opened  and  shut  her  mouth  served  to  inspire 
belief  in  the  reality  of  the  tonic  tic  of  certain  authors. 
As  a  matter  of  fact,  tonic  tics  do  exist,  and  are  some- 
times associated  with  another  variety  known  as  mental 
trismus,  to  the  discussion  of  which  we  shall  revert  ere 
long. 

The  action  of  the  muscles  of  the  lips  is  manifold  i 
whether  in  the  expression  of  the  emotions,  or  in  the 
discharge  of  different  functions,  they  come  into  play 
in  miscellaneous  modes  that  may  be  the  forerunners  of 
a  multiplicity  of  tics.  Of  these,  two  types  may  be 
distinguished,  according  as  expansion  or  occlusion  of 
the  labial  orifice  predominates.  Under  the  one  heading 
come  the  caricatures  of  ordinary  smiling  or  laughing, 
under  the  second  those  that  exaggerate  the  pursing  or 
pouting  movements  whereby  we  are  wont  to  indicate 
chagrin,  repugnance,  disdain,  etc.  Labial  tics  of  this 
nature  may  be  styled  tics  of  facial  mimicry. 

In  the  infant  that  has  long  been  weaned,  and  a 
fortiori  in  the  adult,  the  continuance  of  the  act  of 
sucking  must  of  course  be  considered  a  functional 
anomaly ;  and  while  no  doubt  it  is  true  we  use  our 
lips  in  imbibing  a  beverage  through  a  straw,  or  in 
extracting  the  juice  from  a  fruit,  the  action  is  different 
from  that  of  the  infant,  and  in  any  case  not  to  be 
compared  with  incessant  sucking  of  tongue  or  thumb, 
or  of  some  object  devoid  of  all  nutritive  value — merely 
a  bad  habit,  perhaps,  but  frequently  indistinguishable 
from  tic. 


THE  DIFFERENT   TICS  157 

The  most  fruitful  source  of  the  tics  under  con- 
sideration is  to  be  found  in  labial  cracks  and  dental 
mischief.  More  especially  in  children,  towards  the 
end  of  the  first  dentition,  the  torment  of  loose  teeth 
calls  forth  interminable  devices  for  relief,  in  seeking 
which  tongue  and  lips  pleasurably  co-operate.  Once 
the  tooth  is  out,  the  lacuna  it  leaves  provides  a  new 
sensation  and  a  new  reason  for  muscular  activity. 
Irregularity  of  the  permanent  teeth  may  also  be 
referred  to  as  a  potent  factor  in  the  causation  of  tic. 
It  is  therefore  not  superfluous  systematically  to  examine 
the  teeth  of  all  patients  suffering  from  tics  of  the 
mouth,  and  to  extract  any  offender. 

TICS    OF    THE    CHIN 

The  muscles  of  the  chin  collaborate  with  other 
facial  muscles  in  expressional  movement,  and  are 
similarly  liable  to  be  the  seat  of  tics. 

Massaro1  has  observed  an  interesting  series  of  isolated 
"geniospasm"  occurring  in  twenty-six  individuals  of 
the  same  family  during  five  generations.  The  cha- 
racteristic feature  of  these  spasms  was  an  involuntary 
intermittent  clonic  contraction  of  the  transverse  muscles 
of  the  chin,  suggesting  the  look  of  one  seized  with  fear 
or  with  cold.  The  will  did  not  always  effect  their 
inhibition,  while  emotion  appeared  to  aggravate  and 
distraction  to  abate  their  intensity.  With  sleep  they 
vanished  entirely. 

TICS  OF  THE  TONGUE-LICKING  TICS 

Tics  confined  exclusively  to  the  tongue  are  of  rare 
occurrence.  Moreover,  they  must  be  strictly  differen- 
tiated from  the  tonic  or  clonic  contractions  of  the 

1  MASSARO,  II  pisani,  fasc.  i.  1904. 


158         TICS  AND    THEIR   TREATMENT 

tongue  muscles  met  with  in  hysteria,  epilepsy,  and 
Sydenham's  chorea,  from  the  varying  tremors  that 
accompany  organic  disease  of  cerebral  or  bulbo-pontine 
origin,  as  well  as  from  those  "  glosso-spasms  "  that  may 
or  may  not  be  associated  with  twitches  of  the  facial 
musculature. 

Functional  polymorphism  is  no  less  marked  in  the 
case  of  the  tongue  than  in  that  of  the  lips  ;  it  partici- 
pates in  suction,  mastication,  deglutition,  as  well  as  in 
respiration,  phonation,  and  articulation,  while  to  "  put 
out  the  tongue  "  at  any  one  is  equivalent  to  an  expres- 
sion of  contempt.  It  is,  accordingly,  no  surprise  to  find 
the  number  of  tongue  tics  very  considerable.  Such, 
for  instance,  is  the  licking  tic,  where  the  tongue  is 
constantly  being  passed  over  the  free  border  of  the 
lips,  moistening  them  to  excess ;  or  the  chewing  tic, 
in  which  its  perpetual  motion  inside  the  mouth  in 
every  direction  conveys  the  impression  that  the  subject 
is  chewing  something.  Further,  its  contact  with  the 
palate  or  the  upper  lip  may  yield  different  clucking, 
whistling,  or  crowing  sounds.  Letulle  remarks  that 
the  trick  of  producing  a  little  inspiratory  whistle  by 
the  passage  of  a  column  of  air  through  an  incompletely 
closed  labial  commissure — a  common  habit  among 
people  suffering  from  dental  caries — is  not  slow  in 
developing  into  an  actual  tic. 

It  has  not  fallen  to  our  lot  to  observe  the  tonic 
variety  of  tongue  tics,  none  the  less  must  we  believe 
in  the  possibility  of  their  occurrence.  Convulsive 
lingual  movements,  consecutive  to  disease  of  mouth  or 
teeth,  or  to  lesions  of  corresponding  nerves,  are  in 
all  probability  ^spasms  properly  so  called,  to  which 
disturbances  of  sensation  and  of  nutrition  are  often 
superadded.  The  tonic  contractions  of  tongue,  lips,  and 
masseters,  which  have  been  described  in  cases  of  hypo- 
chondriasis  and  puerperal  psychosis,  are  much  more 


THE  DIFFERENT   TICS  159 

nearly  allied  to  the  tonic  type  of  tic,  if,  indeed,  they  are 
not  to  be  identified  with  it.  A  case  has  been  put  on 
record  by  Lange  of  tonic  contraction  of  the  tongue 
during  speaking  and  eating,  each  time  that  it  touched 
the  dental  arches.  No  doubt  the  condition  was  a  sort 
of  tonic  tic.  Sometimes  players  of  wind  instruments 
are  afflicted  with  a  "  professional  cramp  "  of  the  tongue, 
as  Striimpell  has  reported. 

Generally  speaking,  however,  it  is  particularly  in 
tics  of  language,  and  in  the  various  kinds  of  stammering, 
that  the  tongue  muscles  are  concerned. 

TIC5  OF  THE  JAWS— BITING  TICS— TICS  OF 
MASTICATION 

When  the  muscles  of  mastication  are  the  site  of 
tics,  a  medley  of  nibbling  and  mumbling  results, 
from  which  convulsive  movements  of  the  same  muscles 
consequent  on  cerebro-spinal  mischief  must  be  scrupu- 
lously separated.  A.  von  Sarbo's l  case  of  clonic 
maxillary  spasm  secondary  to  worry,  depression,  and 
an  accident  to  the  head,  in  a  woman  thirty-four  years 
old,  and  otherwise  free  from  stigmata — analogous  cases 
are  quoted  by  Striimpell  and  Ranschburg — was  referred 
by  him  to  a  "  spasm  diathesis,"  akin  to  the  "  diathesis 
of  contracture,"  but  its  etiology  and  evolution,  together 
with  a  striking  exaggeration  of  the  knee  jerks,  negative 
the  hypothesis  of  tic. 

The  masseters  are  chiefly  but  not  exclusively 
affected.  Unilateral  implication  of  the  pterygoids  has 
been  noted  by  Leube  in  a  young  girl  who  was  also 
an  hysteric  and  a  choreic.  A  patient  of  ours  prefaces 
every  conversation  by  rapidly  raising  or  lowering  his 
inferior  maxilla  four  or  five  times,  and  blinking  at  the 

1  A.  VON  SARBO,  "Ein  Fall  von  klonischem  Masseteren  Krampf," 
Monatsch.f.  Psych,  u.  Neur.t  1900,  p.  493. 


160         TICS  AND    THEIR    TREATMENT 

same  time  ;  the  performance  has  its  variants,  moreover, 
with  the  occasional  addition  of  several  nasal  expirations. 

Chattering  or  grinding  of  the  teeth  is  a  frequent 
accompaniment  of  the  tics  we  are  considering,  and 
may  have  a  disastrous  issue  in  the  loosening,  cracking, 
or  breaking  of  these  structures,  as  in  the  case  of  O. 

A  still  more  common  incident  is  injury  to  the  buccal 
mucous  membrane,  a  significant  instance  of  which  is 
furnished  by  an  episode  in  the  history  of  young  J. 

One  day  in  June,  1900,  J.  experienced  a  feeling  of  discomfort 
in  the  articulation  of  the  lower  jaw — the  sequel,  as  a  matter  of  fact, 
to  a  slight  alveolo-dental  periostitis  in  the  neighbourhood  of  a  bad 
tooth — and,  interpreting  the  sensation  as  a  new  and  grave  symptom  in 
the  march  of  his  malady,  forthwith  proceeded  to  investigate  its  de- 
velopment by  playing  with  his  maxilla.  Then  ensued  a  perfect  debauch 
of  masticatory  movements,  in  which  agreeable  repetition  of  every 
conceivable  grimace  was  joined  to  protrusion  and  retraction  of  the 
jaw  in  the  search  after  articular  cracks.  He  became  so  wholly  pre- 
occupied with  this  tic  of  mastication  that  ere  long  he  had  begun  to 
pinch  the  mucous  membrane  on  the  inside  of  the  right  cheek  between 
the  hindmost  molars,  and  this  fresh  object  of  absorbing  attention 
in  its  turn  led  quickly  to  some  excoriation  of  the  mucosa  on  both 
sides.  No  halt  was  called  by  the  lower  jaw  to  give  the  abrasions 
time  for  repair,  with  the  natural  outcome  that  they  suppurated  and 
paved  the  way  for  an  attack  of  infective  stomatitis  with  pain,  fever, 
and  malaise,  which  necessitated  the  application  of  the  thermo-cautery 
to  the  ulcerated  areas  for  its  relief. 

The  explanation  given  by  the  patient  of  the  evolution  of  the  process 
was  controlled  by  interrogation  of  the  parents,  and  no  doubt  was  left 
as  to  its  genuineness.  In  the  attempt  to  dispel  the  articular  discomfort, 
he  had  accidentally  bitten  himself,  but  the  consequent  pain  did  not  deter 
him  from  repeating  and  continuing  the  act  until  its  execution  was 
irresistible. 

In  these  and  similar  cases,  the  infelicitous  rehearsal 
of  the  movements  of  mastication  is  practically  always 
associated  with  an  imperative  desire  to  experience  a 
sensation  at  the  place  actually  bitten.  Cheilophagic 
children,  who  bite  their  lips  unceasingly,  usually 
commence  by  nibbling  at  some  half-separated  fragment 


THE  DIFFERENT   TICS  161 

of  epithelium  on  the  edge  of  a  labial  fissure,  with  the 
inevitable  result  that  the  erosion  is  enlarged  and  fresh 
particles  of  the  mucous  membrane  are  detached.  Youth- 
ful candidates  for  tics  can  scarce  escape  from  the 
vicious  circle.  A  juvenile  patient  of  ours,  F.,  was  in 
the  habit  of  gnawing  so  vehemently  at  the  most  insigni- 
ficant little  irregularity  of  the  mucosa  that  his  lips  were 
constantly  chapped  and  bleeding,  and  as  they  were  no 
less  constantly  being  moistened  by  saliva,  a  succession 
of  new  cracks  made  their  appearance,  to  be  promptly 
torn  apart  by  the  teeth.  Local  applications  of  nauseous 
substances  are  not  always  sufficient  to  discourage  these 
young  u  cheilophagics." 

It  is  still  more  frequent  to  meet  with  onychophagia, 
a  condition  rightly  held  to  be  a  stigma  of  degeneration, 
and  acknowledging  the  same  pathogenic  mechanism 
as  all  biting  tics. 

So  much  for  the  clonic  tics  of  mastication :  we  pass 
on  to  review  the  tonic  forms,  the  most  curious  of  which 
has  received  the  name  of  mental  trismus. 


MENTAL  TRISMUS 

The  characteristic  feature  of  this  tonic  tic  is  an  all 
but  permanent  contraction  of  the  masseters,  which  may, 
however,  be  completely  relaxed  by  making  the  subject 
put  out  his  tongue,  show  his  throat,  etc.  It  may  be 
maintained  during  the  act  of  speaking.  Its  intensitj7 
and  its  persistence  alike  stand  in  rigorous  relation  to 
the  nature  and  degree  of  the  mental  affection  that 
provides  its  occasion.  In  the  insane  it  may  become 
so  absolute  an  obstacle  to  nutrition  that  recourse  must 
be  made  to  nasal  feeding.  Mental  trismus  resembles 
mental  torticollis  in  that  any  proceeding  to  which  the 
patient  attributes  a  special  inhibitory  virtue  is  adequate 
to  correct  it,  as,  for  instance,  the  insertion  of  a  cork 

ii 


162          TICS  AND    THEIR    TREATMENT 
between  the  teeth,1  or  the  placing   of  a  finger  on  the 


incisors.* 

It  must  of  course  be  clearly  understood-  that  the 
diagnosis  of  mental  trismus  can  be  arrived  at  only 
after  previous  elimination  of  every  possible  source  of 
confusion,  such  as  tetanus,  more  rarely  tetany,  menin- 
gitis, and  acute  bulbar  paralysis,  in  addition  to  other 
mesencephalic  and  perhaps  also  certain  cortical  lesions. 
One  is  inclined  to  be  less  dogmatic  where  tonic  or  clonic 
convulsions  of  the  jaws  succeed  violent  fright,  as  in  a 
case  of  trismus  of  nine  months'  duration  recorded  by 
Billot  and  Francotte.  For  that  matter,  trismus  is  met 
with  in  hysteria,  and  may  be  regarded  as  a  manifestation 
of  that  disease,  although  this  cannot  always  be  invoked 
as  its  cause.  We  are  not  attracted  by  Kocher's  idea 
of  assigning  it  to  an  "idiopathic  spastic  neurosis," 
preferring  to  ally  it  to  tics  of  the  tonic  variety. 

Among  the  crowd  of  circumstances  that  reflexly 
give  rise  to  trismus  may  be  enumerated  abscess, 
caries,  alveolo-dental  periostitis,  eruption  of  the 
wisdom  teeth,  disease  of  the  maxilla  and  the  neigh- 
bouring soft  parts,  and  less  commonly  myositis  or 
injury  to  the  masseters.  But  so  long  as  any  one  of 
these  causes  is  in  operation,  and  especially  if  the 
affection  be  attended  with  pain,  we  are  dealing  with  a 
trismus  spasm,  not  a  trismus  tic. 

S.,  whose  psychical  imperfections  have  already 
formed  the  subject  of  remark,  supplies  an  example  of 
the  combination  of  mental  trismus  and  torticollis,  the 
former  being  the  outcome  of  an  inopportunely  reiterated 
voluntary  act,  and  therefore  comparable  to  the  tics. 

S.  speaks  with  clenched  teeth.  His  masseters  are  generally  in 
a  state  of  contraction,  yet  when  he  is  requested  to  put  out  his  tongue 
or  to  open  his  mouth,  and  when  he  is  eating  or  engaged  in  an  animated 

1  RAYMOND  AND  JANET,  Ntvroses  et  idees  fixes,  vol.  ii.  p.  381. 
1  CHATIN,  Rev.  nevrologique,  1900,  p.  310. 


THE  DIFFERENT   TICS  163 

conversation,  any  and  every  movement  of  the  inferior  maxilla  is  ac- 
complished with  the  greatest  ease.  According  to  his  story,  this  tonic 
tic  of  the  masseters  had  its  origin  in  the  forcible  efforts  he  used  to  make 
to  master  his  torticollis,  in  the  course  of  which  he  would  close  his 
mouth  firmly  ;  by  dint  of  continual  repetition  the  habit  developed 
into  a  tic,  and  persists  apart  altogether  from  any  endeavour  of  his  to 
prevail  against  the  wryneck. 

One  of  us  has  had  a  recent  opportunity  of  examining 
a  young  woman  whose  obsessions  and  fixed  ideas,  and 
tics  of  face  and  neck,  indicated  an  extreme  degree  of 
mental  instability,  in  spite  of  intellectual  power  above 
the  average,  in  whom  trismus  of  this  type  was  very 
obvious  during  eating  and  speaking.  No  effort,  how- 
ever concentrated,  to  open  the  mouth  was  then  of  any 
avail;  yet,  on  the  other  hand,  she  could  sing  to  per- 
fection, and  she  could  yawn,  or  show  her  tongue  or  her 
throat,  in  an  entirely  easy  and  normal  fashion. 

The  appearance  of  this  trismus  during  the  perform- 
ance of  certain  functional  acts,  and  of  these  alone., 
is  unequivocal  evidence  of  its  mental  derivation. 


TICS  OF  THE  NECK— NODDING  AND  TOSSING  TICS— TICS 
OF  AFFIRMATION,  NEGATION,  AND  SALUTATION 

Regionally  considered,  the  neck  is  second  only  to 
the  face  in  furnishing  the  greatest  number  of  tics. 
Convulsive  movements  of  the  neck  muscles  produce 
displacement  of  the  head  in  all  sorts  of  ways  and 
directions,  giving  rise  to  clonic  tics  of  affirmation, 
negation,  and  salutation,  and  to  nodding  tics,  as  well 
as  to  an  important  group  of  tonic  tics  which  find 
expression  in  differing  forms  of  torticollis.  The  latter 
are  so  distinctive  in  symptomatology  and  evolution, 
and  have  been  the  centre  round  which  so  much 
discussion  has  raged,  that  a  chapter  must  be  set 
apart  for  their  special  study. 

Restricting    ourselves   for  the  present  to   such   as 


164         TICS  AND    THEIR    TREATMENT 

are  included  in  the  category  of  clonic  convulsions, 
we  find  here  abrupt  vertical  or  horizontal  move- 
ments, as  well  as  intermediate  varieties  compounded 
of  elevation,  depression,  inclination,  or  rotation.  The 
most  ordinary  kind  is  a  sudden,  brief  jerk  or  toss 
of  the  head,  repeated  at  irregular  intervals,  and 
followed  by  instantaneous  resumption  of  the  primary 
position. 

Certain  convulsive  affections — for  instance,  the 
spasmus  nutans  of  young  children,  the  salaam  tic,  and 
what  are  known  as  "baboon  movements  " — are  still  rather 
obscure  and  in  many  cases  seemingly  not  equivalent 
to  tics.  Their  occasional  association  with  strabismus  or 
nystagmus  constitutes  a  plea  for  their  possible  depen- 
dence on  some  encephalic  lesion.  In  two  cases  under 
Oppenheim's  observation  the  nodding  spasm  appeared 
solely  in  the  hours  of  the  night  and  during  sleep.  From 
want  of  more  precise  knowledge  we  must  confine 
ourselves  to  the  remark  that  conditions  analogous  to, 
though  not  identical  with,  the  tics,  in  addition  to 
others  more  specifically  hysterical,  have  probably  been 
incorporated  with  them. 

It  is  a  task  of  peculiar  difficulty  to  determine  the 
share  in  the  final  product  to  be  apportioned  to  indi- 
vidual muscles,  of  which  the  sternomastoids,  as  being  the 
most  superficial  and  the  most  obvious,  are  apparently 
comprised  the  oftenest,  though  the  trapezius  and  the 
muscles  of  the  underlying  strata,  such  as  the  splenius, 
complexus,  and  other  smaller  ones,  may  also  assist. 


According  to  Guinon,  isolated  contraction  of  one  sternomastoid, 
whereby  the  head  is  rotated  and  inclined  once  or  twice  or  several 
times  consecutively,  to  the  usual  accompaniment  of  facial  contortions, 
is  very  frequently  to  be  noted.  If  there  occur  simultaneous  con- 
traction of  the  platysma,  its  fibres  will  be  seen  to  line  the  cervical 
integuments  longitudinally  from  the  chin  to  the  infraclavicular  fossa. 
Synchronous  involvement  of  the  two  sternomastoids  will  flex  the  head 


THE   DIFFERENT   TICS  165 

and  approximate  the  chin  almost  to  the  sternum,  but  more  commonly 
there  is  only  a  slight  forward  inclination  of  the  head  exactly  similar 
to  a  gesture  of  assent.  Extension  and  lateral  deviation  are  less  generally 
encountered. 

Extreme  variability  characterises  the  exciting  causes 
of  these  tics.  It  has  been  remarked  more  than  once  that 
insecurity  of  the  headgear  the  subject  happens  to  be 
wearing  ought  to  be  blamed ;  instead  of  readjustment 
with  the  hand,  a  little  toss  of  the  head  will  make  the 
hat  sit  properly,  and  one  need  not  search  further  afield 
for  the  germ  of  the  patient's  tic.  We  have  been  able 
to  trace  this  mode  of  inauguration  quite  as  conspicuously 
in  young  men  as  in  young  women.  Prohibition  of 
unstable  head  coverings  and  resort  to  exercises  of 
immobilisation  suffice  for  the  tic's  correction  in  early 
cases. 

A  not  infrequent  accessory  symptom — viz.  elevation 
of  the  corresponding  shoulder — may  have  a  similar 
origin  in  peripheral  excitation  connected  with  the 
patient's  clothing.  To  escape  the  annoyance  of  a 
high  and  narrow  collar,  or,  on  the  other  hand,  to 
experience  an  agreeable  sensation  by  rubbing  the  skin, 
it  is  a  very  simple  and  a  very  easy  matter  to  lean  the 
head  on  the  shoulder,  and  to  raise  the  latter  at  the 
same  time.  The  automatic  reproduction  of  this  gesture 
eventually  ends  in  the  formation  of  a  tic  which  removal 
of  the  collar  entirely  fails  to  suppress.  The  first 
therapeutic  indication,  nevertheless,  is  to  interdict  the 
wearing  of  the  unsuitable  collar,  and  to  recommend 
the  adoption  of  others  softer  and  more  ample.  What- 
ever be  the  opinion  one  holds  on  the  mechanism  of 
tic,  the  influence  of  peripheral  stimuli  is,  according 
to  Pierre  Marie,1  very  considerable,  and  it  is  his 
invariable  practice,  in  the  case  of  youthful  subjects, 
to  impress  on  the  parents  the  desirability  of  paying 

1  PIERRE  MARIE,  Rev.  neurologique,  1901,  p.  426. 


166         TICS  AND   THEIR   TREATMENT 

special   attention  to   their   children's   clothing,  and  of 
discarding  any  article  that  is  either  stiff  or  heavy. 

In  one  of  our  cases,  a  girl  A.,  suffering  from  a  nodding  and 
rotatory  tic  of  the  head,  examination  of  the  cervical  region  revealed 
the  existence  of  a  line  of  cicatrices  along  the  margin  of  the  sterno- 
mastoid,  the  vestiges  of  a  previous  operation  for  a  severe  tuberculous 
adenitis.  Some  nerve  filaments  entering  the  sternomastoid  and  trapezius 
had  no  doubt  been  cut,  since  these  muscles  presented  a  minor  degree 
of  atrophy,  and  the  irritation  arising  therefrom,  as  well  as  that  due 
to  dragging  on  the  adhesions  between  the  cicatrices  and  the  under- 
lying tissues,  had  been  the  starting-point  of  a  motor  reaction  primarily 
convulsive  and  involuntary,  but  eventually  habitual  and  automatic,  and 
therefore,  with  the  subsidence  of  the  excitation,  a  tic. 

In  another  case l  a  month's  systematic  treatment 
served  to  curtail  to  a  noteworthy  extent  spasmodic 
head  movements  resembling  those  one  makes  to  get 
rid  of  a  fly. 

From  another  point  of  view,  some  of  the  tics  of 
this  class  are  merely  the  exaggeration  of  certain 
functions  destined  for  the  expression  of  the  ideas 
of  affirmation  and  negation.  The  nod  of  the  head 
with  which  little  G.  used  to  punctuate  his  "yes's" 
was  logical  enough,  but  he  soon  began  its  repetition 
irrespective  of  his  topic  of  conversation,  and  even  when 
saying  "  no  " — a  veritable  tic  of  affirmation. 

Numbers  of  people  are  in  the  habit  of  emphasising 
their  words  with  those  to-and-fro  movements  of  the 
head  that  we  call  gestures  of  approval.  Now,  if 
the  gesture  be  strictly  appropriate  to  the  thought 
present  in  the  mind,  it  cannot  be  identified  with  the 
tics.  On  the  other  hand,  its  execution  may  be  inoppor- 
tune, in  which  case,  provided  the  form  remain  normal, 
it  is  merely  a  stereotyped  act,  and  must  exhibit  | 
the  additional  features  of  abruptness  and  exaggera- 
tion ere  it  rank  as  a  tic. 

1  BRISSAUD  AND  FEINDEL,  Journ.  de  neurologic,  April  15,  1888. 


THE   DIFFERENT   TICS  167 

It  is  chiefly  among  the  mentally  infirm,  such  as 
idiots  and  imbeciles,  that  the  phenomenon  of  salutation 
occurs,  and  as  its  rhythm  is  an  element  which  is 
foreign  to  most  ordinary  tics,  it  is  not  likely  to  be 
confounded  with  them. 

These  conditions  apart,  however,  there  is  one 
highly  specialised  clinical  type  that  merits  separate 
study — viz.  mental  torticollis. 


MENTAL  TORTICOLLIS 

The  medical  world  has  long  been  familiar  with 
various  kinds  of  permanent  or  intermittent  torticollis 
presumably  unconnected  with  muscular,  articular,  or 
osseous  lesions  of  the  neck,  and  been  as  long  divided 
on  the  question  of  their  tabulation. 

Instances  of  this  affection,  bearing  such  widely 
differing  names  as  "  hyperkinesis  of  the  accessory  of 
Willis,"  "  spasmodic  torticollis,"  "  functional  spasm  of  the 
neck  muscles,"  "rotatory  tic,"  etc.,  have  abounded  in 
medical  literature  ever  since  the  days  of  Duchenne  of 
Boulogne,  Trousseau,  and  Charcot.  Some  twelve  years 
ago  now,  the  term  mental  torticollis  was  applied  by 
Brissaud1  to  a  type  of  convulsion  of  the  neck  mus- 
culature whose  association  with  psychical  disturb- 
ances justified  its  description  as  a  tic,  and  his 
opinions  have  been  abundantly  confirmed  by  later 
observation. 

As  a  matter  of  fact,  mental  torticollis  is  a  tic  which 
the  patient  can  ordinarily  curb  by  some  procedure  of 
his  own  invention.  It  has  its  raison  d'etre  in  his  mental 
imperfection.  To  obviate  misunderstanding,  we  must 
premise  that  the  latter  term  is  not  synonymous  with 
mental  alienation.  It  merely  signifies  that  lack  of 

1  BRISSAUD,  "  Tics  et  spasmes  chroniques  de  la  face,"  Joutn.  de 
med.  et  de  chir.  pratiques,  January  25,  1894. 


168         TICS  AND    THEIR    TREATMENT 

mental  balance,  to  whatever  extent,  that  is  patent  in 
all  sufferers  from  tic. 

From  the  motor  aspect  the  tic  under  consideration 
may  be  characterised  as  a  functional  disorder,  con- 
sisting in  the  illtimed,  inapposite,  unceremonious,  and 
exaggerated  repetition  of  the  function  of  head  rotation. 
Notwithstanding  the  large  number  of  muscles  involved, 
the  various  modifications  of  movement  possible,  and  the 
consequent  complexity  of  clinical  types,  each  individual 
case  is  recognisable  as  a  tic.  Let  but  momentary 
cessation  of  the  muscular  spasm  be  effected,  and  the 
torticollis  disappears  without  leaving  a  trace.  Instan- 
taneous and  total  prevention  is  in  practically  every 
case  attainable  by  resort  to  some  subterfuge,  however 
vehement  be  the  patient's  contortions. 

This  device,  whatever  it  be,  may  be  called  the 
"efficacious  antagonistic  gesture,"  of  which  the  simple 
placing  of  the  index  finger  on  the  chin  may  be  cited 
as  an  example.  Its  field  of  operation  is  not  limited  to 
mental  torticollis,  and  we  shall  have  opportunities  of 
observing  its  working  in  greater  detail  in  other  tics  ;  but 
in  the  former  affection  the  constancy  of  its  occurrence 
and  the  facility  of  its  detection  combine  to  enhance  its 
diagnostic  value. 

We  hasten  to  remark,  however,  that  conditions  other 
than  those  we  have  just  mentioned  are  capable  of 
producing  convulsive  movements  in  the  muscles  of  this 
region.  In  addition  to  such  osseous,  articular,  and 
muscular  alterations  as  may  determine  a  more  or  less 
permanent  torticollis,  certain  nervous  lesions  are  apt  to 
be  succeeded  by  the  development  of  the  spasmodic  form, 
no  longer  as  a  tic,  but  as  a  true  neck  spasm,  the  due 
recognition  of  which  may  be  a  matter  of  no  little 
perplexity. 

Confining  our  attention  for  the  present  to  torticollis 
tic — the  mental  torticollis  of  Brissaud — we  notice,  in  the 


THE  DIFFERENT   TICS  169 

first  place,  that  it  affects  either  sex  indifferently.  The 
age  of  our  youngest  patient  was  eighteen,  though  in  a 
case  of  Raymond  and  Janet's  the  disease  made  its  appear- 
ance four  years  earlier.  A  hereditary  neuropathic  or 
psychopathic  factor  is  invariable,  but  similar  heredity 
is  the  exception.  Paternal  alcoholism  has  been  quoted 
by  Guibert  as  a  possible  predisposing  cause,  also  a  rheu- 
matic diathesis  (Bompaire),  family  trembling  (Feindel), 
hereditary  stammering  (Nogues  and  Sirol),  nervous 
and  mental  disease  in  the  parents  (Feindel  and  Meige). 
One  of  Oppenheim's  patients  had  a  peculiarly  sinister 
family  history :  the  grandparents  were  related  by 
blood,  one  being  a  diabetic  as  well,  and  the  other 
a  lunatic ;  the  mother  was  nervous,  and  the  sisters 
either  epileptic  or  psychically  abnormal.  This  case  was 
characterised  by  the  existence  of  generalised  tics  in 
childhood,  and  by  the  development  of  torticollis  soon 
after  marriage. 

Among  personal  antecedents  may  be  noted  hysterical 
attacks  (Sgobbo),  emotional  unrest  (de  Buck1),  migraine 
(Brissaud),  neuralgia  (Bompaire),  irritability,  eccentricity, 
caprice,  absentmindedness,  neurasthenia  (Brissaud  and 
Meige2).  Other  favouring  circumstances  are  moral 
shock,  intense  and  prolonged  emotion,  remorse,  pre- 
occupation (Bompaire,  Sgobbo,  Brissaud  and  Meige, 
Grasset).  Purely  extraneous  causes  seem  sometimes  to 
be  the  starting-point ;  for  instance,  toothache  and 
dental  inflammation  (Souques  3),  pain  in  the  neck  from 
carrying  heavy  loads  (Amussat3),  chill  (Legouest,  de 
Buck,  Guibert3). 

At  the   Congress   of  Limoges  a  case  was  reported 

1  DE  BUCK,  "  Spasme  fonctionnel  du  cou,"  Belgique  medtcale,  1897, 
No.  51. 

2  BRISSAUD  AND  MEIGE,  "  Trois  nouveaux  cas  de  torticolis  mental," 
Rev.  neurologtque,  1894,  p.  697. 

3  Cited  by  BOMPAIRE,  These. 


170         TICS  AND    THEIR    TREATMENT 

by  Lanuois  where  the  onset  of  torticollis  in  a  young 
girl  was  determined  by  an  overpowering  impulse  to 
gaze  at  a  little  papilloma  on  her  nose.  The  extirpa- 
tion of  the  growth  was  followed  by  an  ameliora- 
tion of  symptoms  that  amounted  substantially  to  a  cure. 

Mental  torticollis  consecutive  to  anthrax  of  the  neck 
has  been  described  by  Briand. 

Other  conditions  that  have  been  invoked  as  possible 
causes  are  the  intoxications  and  infections,  alcoholism, 
saturnism,  mercury  poisoning,  typhus,  pneumonia, 
paludism,  etc.  Oppenheim  has  signalised  the  reappear- 
ance, after  several  months  of  respite,  of  a  torticollis 
secondary  to  an  attack  of  influenza.  Overwork,  accident, 
occupation,  have  in  their  tuni  been  suggested.  In  some 
cases,  as  a  matter  of  fact,  it  does  seem  that  the  last 
is  of  some  import,  since  the  incidence  of  the  torticollis 
is  to  a  certain  extent  on  those  muscles  that  have  been 
actively  employed  in  the  pursuit  of  a  profession,  and  they 
thus  acquire  a  sort  of  functional  hyperkinesis. 

Graft's l  case  of  clonic  convulsive  contractions  of 
the  left  splenius,  left  deep  rotators,  and  right  sterno- 
mastoid,  occurred  in  an  individual  obliged,  when  carry- 
ing heavy  loads,  to  maintain  his  head  in  a  fixed  position 
to  the  left,  and  unable  thereafter  to  turn  it  to  the 
right. 

In  some  quarters  no  little  importance  is  attached 
from  the  pathogenic  point  of  view  to  the  actual  state  of 
the  muscles,  and  in  particular  to  atrophy  or  hypertrophy 
of  the  sternomastoids.  Fere  holds  that  sometimes 
unilateral  atrophy  may  occasion  abnormal  contraction 
of  the  opposite  muscle,  but  such  muscular  changes  are, 
in  our  opinion,  much  less  likely  to  be  the  cause  than 
the  consequence  of  reiteration  of  movement  or  con- 
servation of  attitude.  Legenmann's  case  was  one  of 

1  GRAFF,  "  Ein  Fall  von  spastischen  Krampfen  der  Halsmuskulatur," 
Deutsch.  mtd.  Wochenschrift,  March  22,  1900,  p.  66. 


THE  DIFFERENT   TICS  171 

tonic  and  clonic  convulsion  of  the  right  sternomastoid 
where  there  was  a  cartilaginous  tumour  in  the  left. 

The  role  played  by  ocular  affections,  by  troubles 
of  vision  and  of  accommodation,  in  the  genesis  of 
wryneck  is  frequently  no  insignificant  one,  and  it  is 
curious  how  often  patients  attribute  the  mischief  to 
the  strain  of  overwork  in  bad  light.  Strabismus 
(Walton)  and  ocular  palsies  (Nieden)  have  also  been 
known  to  lead  to  lateral  deviation  of  the  head  and 
permanent  torticollis.  There  has  been  described  a 
variety  ab  aure  Icesa. 

Albeit  these  factors  have  a  share  in  determining  the 
gesture  and  attitude  adopted  by  the  patient,  the  resulting 
torticollis  is  not  of  necessity  mental.  That  which,  ac- 
cording to  Romberg,  is  provoked  by  compression  of 
supraclavicular  nerve  filaments  is  unmistakably  a  spasm. 

To  establish  the  diagnosis  of  mental  torticollis,  the 
existence  of  those  psychical  anomalies  that  are  common 
to  all  who  tic  must  first  be  substantiated,  and  then 
must  one  essay  the  reconstruction  of  its  mechanism. 
The  inquiry  may  at  first  prove  fruitless,  of  course,  but 
continuation  of  the  search  can  scarcely  fail  to  elicit 
tokens  of  mental  infantilism.  In  pursuance  of  this 
quest  we  shall  find  ourselves  face  to  face  with  the  "  big 
baby,"  the  personification  of  childishness,  obstinacy, 
and  caprice ;  we  shall  encounter  the  peevish,  the  sulky, 
the  whining ;  we  shall  see  how  their  impotence  in 
presence  of  their  tic  turns  their  nonchalance  to  pro- 
found despair,  how  their  failure  to  adapt  themselves 
to  their  malady  convicts  them  remorselessly  of  voli- 
tional imperfection.  The  utter  weakness  of  their  will, 
according  to  Dejerine,  justifies  their  being  ranked  as 
neurasthenics ;  but  in  the  latter  class  of  case  obses- 
sional ideas  are  both  fugitive  and  fluctuating,  whereas 
mental  torticollis  is  dependent  on  a  fixed  idea  of 
peculiar  tenacity. 


172         TICS  AND   THEIR   TREATMENT 

There  can  be  no  doubt  that  such  patients,  however 
undimmed  their  intellectual  powers  may  remain,  ulti- 
mately fail  before  the  everlasting  obsession  of  their 
disease,  and  if  in  some  cases  interest  in  daily  life  and 
work  continues  unabated,  a  multitude  of  others  become 
indifferent  and  apathetic,  and  sink  into  a  state  of 
physical  and  moral  infirmity. 

To  retrace  the  steps  in  the  evolution  of  mental 
torticollis  is  a  task  not  always  easy  of  accomplishment. 
Very  commonly  the  affection  supervenes  as  the  sequel  to 
the  unhindered  repetition  of  a  once  voluntary  purposive 
act,  /a  repetition  become  tyrannical  through  volitional 
debility.  One  or  two  extracts  from  published  cases 
will  serve  to  illustrate  the  truth  of  our  contention. 

1.  To  escape  the  pain  of  a  dental  abscess  on  the  right  side,  of  only 
four  or  five  days'  duration,  the  patient  had  acquired  the  habit  of  turning 
the  head  to  the  right  and  maintaining  it  so  for  as  long  as  possible  at 
a  time.     Very  shortly  after  the  healing  of  the  abscess,  the  head  commenced 
to  move  involuntarily  towards  the  same  shoulder  (Souques  '). 

2.  Occipital  neuralgia  and   pain  in  the  neck  led  the  patient  to    try 
various  positions   to  allay  the  agony,  in  the  course  of  which  he  found 
that  rotation  to  the  right  brought  transient  relief.     By  dint  of  repetition 
the  movement  became  involuntary  (Brissaud  and  Meige*). 

3.  In  this  case   the  subject  used  to  spend  the  whole  evening  inert, 
arms  folded,  without   reading  or  working,  tilting  his   head   forwards  or 
backwards   to   rediscover   a   "  cracking "    in    his    neck   from    which    he 
suffered — a  proceeding  that  gradually  developed  into  a  tic  (Brissaud  and 
Meige). 

4.  A  schoolgirl  was  dissatisfied    with  the    place  allotted  to  her   in 
the  schoolroom,  and  pretended  that  she  felt  a  draught  on  her  neck  coming 
from   a   window   on   her  left.     The    initial    movement  was  an  elevation 
of  the  shoulder  as  if  to  bring  her  clothes  a  little  more  closely  round  her 
neck,    then   she   commenced    to   depress   her  head  and  indicate  her  dis- 
comfort by  facial  grimaces,  and  these  eventually  passed  beyond  voluntary 
control  (Raymond  and  Janet  s). 

5.  In   order   to   deceive   his  friends,    the   patient  assumed   a  forced 

1  Cited  by  BOMPAIRE,  Thise  de  Paris,  1894. 

1  BRISSAUD  AND  MEIGE,  Rev.  neurologique,  December  50, 1 894,  p.  697. 

1  RAYMOND  AND  JANET,  Ntvroses  et  idees  fixes,  vol.  ii.  p.  378. 


THE  DIFFERENT   TICS  173 

attitude  of  gaiety  when  really  sick  at  heart,  by  inclining  his  head, 
raising  his  shoulders,  and  arching  his  back,  and  at  the  end  of  a  few 
months  a  bantering  remark  revealed  the  surprising  fact  that  he  could  not 
correct  the  position  (Raymond  and  Janet1). 

6.  A  woman  used  to  pass  the  day  sewing  or  knitting  at  her  window 
and  amusing  herself  from    time  to  time  by  pensively  lookiqg  out  into 
the  street.     Not  long  afterwards    she  noticed  how  much  more  pleasant 
it   was  to   allow   her   head  to   turn  to  the  right,  and  how  troublesome 
it  was  to  keep  it  straight.     At  length  she  found  this  impossible,  except 
with  the  aid  of  her  hands  (Sgobbo  *). 

7.  Worried  by  severe  occipital  pains,  an   individual   became  so  con- 
cerned to  find  they  were  being  replaced  by  a  feeling  of  great  weakness, 
that  he  let  his  head  rest  by  inclining  it  now  and   then  to  the   left,  an 
act  which  he  is  certain  was  the  cause  of  his  torticollis  (Feindel  3). 

One  further  instance  may  be  cited  from  Seglas,4  where  a  neurasthenic 
lady,  fifty  years  old,  had  been  for  three  years  a  martyr  to  vague  pains 
which  finally  settled  in  her  neck,  and  asserted  themselves  on  the  slightest 
exertion.  She  sought  to  mitigate  her  sufferings — a  veritable  topoalgic 
obsession — by  leaning  her  head  on  her  shoulder,  and  the  desire  thus  to 
procure  alleviation  gradually  became  irresistible  and  the  movement 
unconscious. 

Multiplication  of  examples  is  unnecessary.  It  is 
abundantly  evident  from  the  above  that  the  repetition 
of  a  deliberate  and  voluntary  functional  act,  co- 
ordinated and  systematised,  is  the  first  step  in  the 
genesis  of  mental  torticollis. 

The  mere  memory  of  a  frequently  repeated  move- 
ment, especially  if  the  latter  occur  in  the  prosecution  of 
one's  avocation,  may  determine  the  type  of  torticollis, 
as  in  Grasset's  "post-professional  colporteur  tic,"  to 
which  reference  has  already  been  made. 

In  the  case  of  one  of  our  patients,  N.,  the  prolonged 
and  almost  exclusive  use  of  certain  muscles  in  the 

1  RAYMOND  AND  JANET,  loc.  cil.  p.  380. 

1  SGOBBO,  "  Un  caso  di  torticollo  men  tale,"  //  manicomio  moderno, 
1898,  fasc.  3. 

3  FEINDEL,  "  Le  torticolis  mental,"  Gazette  hebdomadaire,  February 
20,  1898,  p.  169. 

4  SEGLAS,  "  Un  cas  de  torticolis  mental,"  Rev.  neurologiqut,  1901, 
p.  114. 


174          TICS  AND    THEIR    TREATMENT 

course  of  his  business  decided  their  involvement  in 
the  condition  of  practically  permanent  torticollis  with 
which  he  was  afflicted,  and  which  was  due  to  strong 
contraction  of  the  right  trapezius  and  sternomastoid. 
It  appeared  that  for  eighteen  years  he  had  been  a 
cutter  in  a  linen  draper's,  where  it  had  been  his  duty, 
for  hours  at  a  stretch,  to  cut  rolls  of  stuffs  with  a 
large  and  heavy  pair  of  scissors,  and  in  the  execution  of 
this  work  the  right  arm  was  extended,  the  hand  firmly 
pressed  on  the  table,  the  shoulder  elevated,  the  head 
rotated  and  inclined  to  the  left. 

We  cannot  do  better  in  this  connection  than  recall 
the  cases  referred  to  by  Brissaud l  when  directing 
attention  for  the  first  time  to  this  variety  of  tics  of 
the  neck. 

Here  is  a  patient  with  energetic  contraction  of  the  muscles  which 
depress  the  head  on  the  neck.  She  holds  her  head  in  her  hands  to 
inhibit  the  movement,  and  succeeds.  And  she  is  quite  convinced  that 
the  force  requisite  for  rectifying  the  vicious  attitude  is  not  simply  the 
power  of  her  will  acting  on  the  muscles  concerned,  but  the  strength  of 
her  hands.  She  has  unconsciously  doubled  her  physical  personality  ; 
her  hands  obey  her  will,  her  neck  does  not.  At  least,  this  would  appear 
to  be  the  key  to  the  situation,  for  it  can  be  well  understood  how 
much  easier  it  would  be  to  readjust  the  position  by  action  of  the  an- 
tagonist cervical  muscles  than  by  the  hands.  The  contraction,  more- 
over, is  entirely  painless.  It  is  a  trivial  act  of  obsessional  insanity,  pro- 
voked by  some  or  other  insignificant  psychomotor  hallucination. 

Take  this  next  man,  who  also  must  needs  keep  his  head  straight 
by  means  of  his  hand — obviously  no  irritation  of  the  spinal  accessory 
can  be  accused  of  originating  the  mischief,  else  would  he  be  unable 
himself  to  replace  his  head.  It  is  merely  the  idea  that  is  urging  him  to 
its  rotation.  Try  by  force  to  prevent  him  from  twisting  his  head 
round,  or  try  to  twist  it  against  his  will,  and  the  difficulty  of  the 
thing  will  be  at  once  comprehended.  Or  try  to  pull  your  own  two 
hands  apart  to  see  which  is  the  stronger,  and  you  will  never  succeed, 
for  the  simple  reason  that  abstraction  of  the  will  is  impossible.  One 
hand  can  prevail  over  the  other  only  if  both  consent  j  the  left  cannot 
be  in  ignorance  of  what  the  right  is  doing.  A  "  partial  "  or  "  local  "  will  is 
inconceivable  ;  there  cannot  be  one  for  the  head  and  another  for  the  arm. 

1  BRISSAUD,  Lepms  sur  les  maladies  neiveuses,  1895,  p.  514. 


THE  DIFFERENT   TICS  175 

Here  is  a  third  patient,  presenting  an  identical  muscular  spasm.  He 
is  content  to  apply  two  fingers  to  his  chin  to  overcome  the  otherwise 
irresistible  bend  of  his  head  to  the  right.  Such  has  been  the  situation 
for  the  last  five  years.  No  line  of  treatment  has  made  any  impression 
on  this  neurosis,  to  which  two  factors  contribute,  though  one  can- 
not say  which  predominates — an  unconscious,  imperious,  motor  im- 
pulse, and  a  conscious  though  ill-informed  volition,  powerless  to 
arrest  the  convulsions  by  simple  and  normal  media,  and  obliged  to 
resort  to  a  puerile  artifice,  to  a  sickly  sort  of  deceit.  The  opposition 
furnished  by  two  fingers  only  cannot  be  of  any  avail,  yet,  however  feeble 
be  the  succour,  the  patient's  imagination  is  thereby  appeased. 

Such  (adds  Brissaud),  fashioned  in  the  same  mould,  are  the  "  mentals  " 
of  whom  I  have  been  speaking.  Recollect  the  ungovernable  impulse  they 
feel  to  execute  a  convulsive  movement  that  their  will  might  thwart  ; 
remember,  therefore,  at  the  same  time,  their  volitional  enfeeblement. 

Brissaud's  earliest  observations  were  followed  at 
no  long  interval  by  various  articles,  first  of  all  the 
thesis  of  his  pupil  Bompaire,1  then  others  in  collabora- 
tion with  ourselves.  The  more  recent  publications  of 
Lentz,2  Sgobbo,  Nogues  and  Sirol,  Raymond  and  Janet, 
Seglas,  Etienne  Martin,  etc.,  may  be  mentioned,  as  well 
as  a  contribution  by  Grasset,3  notable  alike  for  the 
case  it  contains  and  for  the  author's  interpretations. 

The  view  that  considers  of  prime  importance  the 
psychical  phenomena  of  this  affection  has  received 
general  confirmation.  We  have  seen  protracted  cases 
of  "spasm  of  the  accessorius"  cured,  exactly  as  with 
the  tics,  by  widely  differing  therapeutic  agents.  In 
numerous  instances,  according  to  Oppenheim,  torticollis 
is  not  consecutive  to  any  peripheral  or  central  change 
in  the  nervous  system,  but  rather  indicates  irritability 
of  nerve  centres.  It  is  probable  that  the  kinsesthetic 
centres  in  the  cortex  for  the  neck  muscles  are  the  seat 

1  BOMPAIRE,  "  Du  torticolis  mental,"  These  de  Paris,  1894. 

J  LENTZ,  "  Rotation  permanente  de  la  t€te  a  droite,"  Journ.  de 
neurologic,  1897,  p.  502. 

8  GRASSET,  "  Tic  du  colporteur ;  spasme  polygonal  post-profes- 
sionnel,"  Nouv.  icon,  de  la  Salpctriere,  July — August,  1897,  p.  217. 


1 76         TICS  AND   THEIR   TREATMENT 

of  the  lesion,  and  that  their  congenital  and  hereditary 
imperfection  fixes  the  form  the  convulsion  will  take. 

These  and  similar  facts  are  well  calculated  to 
corroborate  the  opinion  that  mental  torticollis  is  nought 
else  than  a  form  of  tic.  The  subjects  of  the  disease  are 
satisfied  of  two  things — that  no  one  and  no  circumstance 
can  hinder  their  torticollis  from  asserting  itself,  and 
that  their  own  antagonistic  gesture  is  the  sole  efficacious 
preventative  at  their  command.  The  attempt  to  put 
the  displacement  right  evokes  acute  pain  and  stimulates 
opposition  on  their  part.  They  prefer  the  display  of 
considerable  resistance  to  the  renunciation  of  their 
satisfaction  in  their  tic,  and  follow  up  any  momentary 
restraint  by  a  riot  of  inco-ordination,  in  recompense 
for  the  brief  sacrifice  they  have  made  to  preserve 
immobility. 

The  muscular  contraction  that  deviates  the  head 
may  be  either  clonic  or  tonic,  bringing  it  to  one  side 
by  a  series  of  convulsions  and  allowing  it  to  resume  its 
original  position  in  the  intervals,  or  forcing  it  to  maintain 
a  vicious  attitude  for  hours.  Innumerable  variants  may 
occur,  indeed  are  the  rule,  even  in  the  same  patient. 
In  short,  though  mental  torticollis  may  generally  be 
classed  as  a  tic  of  attitude,  it  matters  but  little  whether 
the  adoption  of  the  attitude  or  the  attitude  adopted 
constitutes  the  tic.  They  are  simply  two  successive 
phases  in  the  same  abnormal  muscular  act.  The  most 
elementary  movement  is  rotation  of  the  head ;  it  may 
equally  well  be  inclined  on  one  shoulder,  or  be  both 
inclined  and  rotated  to  one  side,  or  it  may  be  inclined 
in  one  direction  and  rotated  in  the  other.  There  may 
be  accompanying  elevation  of  the  shoulder,  or  the  act 
may  become  a  much  more  complex  one,  involving  neck, 
shoulder,  and  arm. 

Each  and  all  of  the  neck  muscles  may  take  a  share 
in  the  torticollic  movement,  but  some  are  more  commonly 


THE  DIFFERENT   TICS  177 

affected  than  others,  in  particular  the  sternomastoid, 
whose  contraction  may  either  be  isolated,1  or  modified 
by  trapezius,  splenius,  levator  anguli  scapulae,  etc.,  of 
the  same  or  the  contralateral  side.  It  is  frequent 
to  find  the  head  inclined  to  one  side  and  rotated  to 
the  other  by  the  action  of  the  sternomastoid,  or  dis- 
placed backwards  and  slightly  turned  to  the  side  of 
the  contraction  by  means  of  the  splenius.  If  the 
sternomastoid  and  homolateral  trapezius  are  acting 
together,  torsion  of  the  neck  is  very  pronounced  and 
the  skin  over  that  area  is  deeply  lined.2  It  may  happen 
that  the  head  is  rotated  and  inclined  to  the  same  side, 
as  in  Grasset's  case,  where  the  curious  combination 
occurred  of  clonic  convulsion  of  left  trapezius  and 
pectoralis  major  with  right  pectoralis  major  and 
sternomastoid.  In  the  same  patient  the  left  arm 
was  pressed  against  the  trunk  and  the  right  extended 
posteriorly. 

There  are  other  instances  where  it  would  be  more 
accurate  to  speak  of  retrocollis,  as  in  a  case  recorded 
by  Brissaud,  or  procollis,  the  two  sternomastoids  con- 
tracting synchronously,  as  in  another  case  due  to 
Duchenne  of  Boulogne.  The  extreme  degree  of  flexion 
induced  in  this  way  was  neutralised  immediately  by 
supporting  the  head ;  the  adoption  by  the  patient  of 
a  reclining  position  sufficed  to  inhibit  the  tic's  mani- 
festation. 

Intensity  and  frequency  of  movement,  duration  and 
deformity  of  attitude,  all  alike  may  vary  in  the  same 
individual  at  differing  times.  Solitude,  tranquillity, 
and  repose  favour  the  diminution  and  even  the  entire 
disappearance  of  spasmodic  movements  which  fatigue, 
anxiety,  and  emotion  are  prone  to  exaggerate.  An  in- 

1  MARECHAL,  "  Un  cas  de  torticolis  spasmodique,"  Journ.  de 
neurologie,  1899,  No.  u. 

*  REDARD,  Le  torticolis  et  son  traitement,  Paris,  1898. 

12 


1 78          TICS  AND    THEIR    TREATMENT 

stmctive  case  in  point  is  one  of  van  Gehuchten's,1  the 
subject  being  a  labourer  twenty-five  years  old,  in  whom 
a  tic  of  the  right  arm  and  right  sternomastoid  of  seven 
years'  continuance  disappeared  whenever  the  patient 
was  by  himself,  to  burst  out  afresh  as  soon  as  he  was 
conscious  of  being  observed. 

Distraction  is  a  valuable  sedative.  A  patient  of 
ours  used  to  pass  the  day  in  twisting  his  head  round 
with  ever-increasing  violence,  while  at  night,  amid  the 
smiling  gaiety  of  the  theatre,  hours  slipped  by  without 
his  betraying  the  least  suspicion  of  his  malady. 

Occupation,  on  the  other  hand,  may  provoke  the 
condition.  Duchenne  has  a  reference  to  a  case  where 
rotation  of  the  head  to  the  right  commenced  whenever 
the  subject  started  to  read,  and  ceased  only  with  the 
laying  down  of  the  book.  In  one  of  our  cases  the  head 
kept  turning  whenever  and  as  long  as  the  two  hands 
were  simultaneously  engaged  in  some  pursuit.  If  one 
hand  was  disengaged,  there  was  no  torticollis. 

As  a  general  rule,  excitement  invites  or  increases 
movement,  whereas  sleep  frustrates  it,  and  after  a  good 
night's  rest  several  minutes  or  even  an  hour  or  two 
may  elapse  ere  the  convulsions  reassert  themselves. 

Acute  pain  is  rarely  met  with  in  the  disease  we  are 
considering,  but  sensations  of  discomfort,  of  tension,  of 
strain  in  the  muscles,  form  a  common  subject  of  complaint. 

By  way  of  example  may  be  cited  the  case  of  one  of 
our  patients: 

L.  is  eighteen  years  old,  and  has  been  suffering  from  torticollis  for 
the  last  six  weeks.  The  chief  movement  is  abrupt  rotation  and  very 
slight  inclination  of  the  head  to  the  right,  and  the  muscles  principally 
concerned  are  the  left  sternomastoid  and  the  right  splenius.  The  head 
is  sunk  between  the  shoulders,  of  which  the  right  one  is  elevated  syn- 
chronously with  the  rotation,  and  remains  so  as  long  as  the  latter  persists. 

1  VAN  GEHUCHTEN,  "  Un  curieux  cas  de  tic,"  Jourtt.  de  neurologic t 
1899. 


THE  DIFFERENT   TICS  179 

The  displacement  is  effected  by  a  moderately  brisk  muscular  contrac- 
tion that  rotates  the  head  to  the  right  on  its  vertical  axis,  and  succeed- 
ing contractions  only  serve  to  accentuate  the  deviation  or  to  maintain 
it  when  the  head  is  beginning  to  revert  to  its  original  position.  There 
are  none  of  those  upward  or  downward  oscillations,  those  hesitating, 
tentative  little  jerks  that  some  patients  make  before  assuming  a  fixed 
torticollic  attitude.  In  L.'s  case  the  duration  of  the  wryneck  is  ex- 
ceedingly variable  ;  sometimes  the  head  returns  spontaneously  to  its 
place,  and  deviates  afresh  immediately  after,  but  its  periodicity  changes 
with  the  days,  and  even  with  the  minutes. 

The  torticollis  is  accompanied  by  a  rather  disagreeable  sensation,  a 
feeling  of  fatigue  in  the  muscles  concerned,  of  "  dragging  "  in  their  bellies 
as  well  as  at  their  insertions.  The  site  of  this  sensation  is  over  the  left 
sternomastoid,  on  the  right  half  of  the  posterior  aspect  of  the  neck,  and 
deep  in  the  right  shoulder,  whereas  the  upper  parts  of  the  trapezii,  the 
left  half  of  the  neck  and  its  anterior  surface,  and  the  right  sterno- 
mastoid, are  areas  that  are  free  from  pain. 

Here,  further,  as  in  all  cases  of  the  same  nature,  the  subjective  sensa- 
tions differ  from  day  to  day,  and  moment  to  moment.  It  is  just  as 
perplexing  to  localise  these  pains  exactly  as  to  fix  the  topoalgia  of  a 
neurasthenic.  The  lack  of  precision  of  the  answers  is  no  doubt  explicable 
by  the  variability  of  the  muscular  contractions. 

Emotion,  apprehension,  the  presence  of  strangers,  tend  to  intensify 
the  spasm,  which  tranquillity  and  rest  will  attenuate.  On  the  other 
hand,  the  most  trivial  incident — a  sudden  noise,  an  unexpected  question, 
the  act  of  swallowing  saliva,  of  putting  out  the  tongue,  etc. — will 
reawaken  the  latent  torticollis  ;  any  surprise,  any  movement,  or  even  the 
idea  of  a  movement,  suffices  for  its  ebullition. 

Under  the  influence  of  the  will,  particularly  after  a  time  of  rest, 
the  head  may  sometimes  reoccupy  the  mid  position  spontaneously,  a 
result  unfailingly  obtained  by  distraction  also,  as  when  the  patient  is 
hearkening  thoughtfully  to  her  father's  conversation.  On  her  "  bad 
days,"  however,  the  use  of  even  considerable  force  fails  alike  to  hinder 
the  head's  turning  and  to  effect  its  replacement.  That  is  to  say,  the 
resistance  offered  by  the  torticollis  to  reduction  may  at  one  moment  be 
nil,  at  another,  feeble,  or  forcible,  or  even  insuperable. 

Some  patients  affected  with  mental  torticollis  seem 
to  have  lost  the  sense  of  position  of  their  head,  others 
evince  a  want  of  precision  and  assurance  in  the  execu- 
tion of  different  limb  movements.  Speaking  generally, 
it  may  be  said  that  downward  movements  of  the  arms 
are  less  good  than  upward  ones,  and  that  their  syn- 


1 8o         TICS  AND   THEIR    TREATMENT 

chronous  and  symmetrical  action  is  accomplished  with 
greater  ease  than  is  the  operation  of  one  only. 

The  debut  of  mental  torticollis  is  usually  insidious. 
Whether  head  or  shoulder  be  implicated  first,  the 
incipient  motor  reaction  is  infrequent,  inconsiderable, 
and  transitory.  Little  by  little  its  frequency  increases 
and  its  duration  lengthens,  till  the  end  of  a  few  months 
sees  the  torticollis  established. 

It  may  happen  that  the  onset  is  so  stealthy  that 
it  eludes  the  subject's  own  notice,  and  attention  is 
called  to  his  peculiar  attitude  by  the  members  of  his 
circle.  Not  seldom  the  earliest  localisation  of  the 
condition  in  a  particular  muscle  is  abandoned  in  favour 
of  some  other,  and  resumed  at  a  subsequent  stage. 
Occasionally  the  torticollis  passes  from  right  to  left, 
or  vice  versa ;  occasionally,  too,  the  clonic  variety  may 
give  way  to  the  tonic  after  a  few  weeks  or  months. 

It  has  been  already  remarked  that  at  the  outset 
the  tic  is  infrequent,  and  may  depend  for  its  manifes- 
tation on  certain  predetermined  circumstances,  as,  for 
instance,  the  exercise  of  the  faculty  of  writing.  Such 
was  the  case  with  S.,  with  P.,  and  with  N. 

N.  was  a  patient  forty-eight  years  old,  with  a  left  torticollis  dating 
back  twenty  months.  His  account  of  its  origin  was  to  the  following 
effect :  for  some  years  he  had  been  employed  in  a  commercial  office, 
where  from  seven  in  the  morning  to  eight  at  night  he  was  occupied 
in  writing,  head  and  body  being  turned  to  the  left.  At  the  beginning 
of  1900,  consequent  on  a  succession  of  troubles,  he  noticed  that  his 
head  was  twisting  round  to  the  left  in  an  exaggerated  fashion  while  he 
was  writing,  and  the  rotation  gradually  began  to  assert  itself  at  other  times, 
when  he  was  reading,  or  eating,  or  buttoning  his  boots.  Even  apart 
from  any  other  act,  the  rotatory  movement  soon  became  incessant,  continu- 
ing while  he  was  on  his  feet,  but  vanishing  completely  if  he  lay  down 
or  if  the  head  was  supported.  At  present  he  has  the  greatest  difficulty 
in  writing,  for  his  head  at  once  deviates  violently  to  the  right. 

The  spasmodic  movements  sometimes  spread  to  the 
shoulder,  arm,  and  trunk,  and,  in  one  of  our  cases,  to  the 


THE  DIFFERENT   TICS  181 

leg.  Should  the  condition  be  advanced,  it  is  frequently 
complicated  by  choreiform  or  athetotic  movements  in 
the  limbs,  or  by  irregular  and  arhythmical  tremors. 

A  case  of  this  nature  was  shown  at  the  Neurological 
Society  of  Paris  by  Marie  and  G-uillain1 : 

The  patient,  forty- nine  years  of  age,  was  suffering  from  muscular 
spasms  that  kept  turning  his  head  first  to  one  side  and  then  to  the  other. 
Fixation  of  the  head  between  the  hands  assured  a  few  moments'  respite, 
but  the  convulsions  were  quick  to  reappear.  The  left  hand  was  con- 
stantly being  brought  up  to  the  face  in  the  endeavour  to  procure  im- 
mobility, while  the  arms  were  the  seat  of  abrupt  jerking  movements 
intermediate  between  tremor  and  chorea. 

The  various  reflexes  were  normal ;  stimulation  of  the  sole  of  the  foot 
evoked  a  flexor  response  on  either  side,  and  no  symptom  of  hysteria  was 
forthcoming.  The  disease  had  made  its  appearance  in  1879,  when, 
without  discoverable  motive,  the  head  had  commenced  to  tremble  and 
to  work  round  to  the  left.  Section  of  the  tendon  of  the  sternomastoid 
did  not  impede  the  development  of  the  affection,  which  two  years  ago 
increased  in  intensity,  when  the  above-mentioned  movements  in  the  arms 
were  superadded.  The  likelihood  seemed  to  be  that  they  were  of  the 
same  nature  and  origin  as  the  torticollis  itself. 

In  reference  to  this  communication,  the  following 
remarks  were  offered  by  Professor  Brissaud : 

It  is  true  of  all  forms  of  functional  hyperkinesis,  that  the  indefinitely 
prolonged  repetition  of  the  same  act  leads  finally  not  merely  to  muscular 
hypertrophy,  but  to  a  ceaseless  over-activity  of  contraction  in  all  the 
muscles  affected.  That  this  hypertrophy  and  hyperexcitability  depend 
on  some  organic  central  lesion  is  not  the  necessary  sequel.  A  purely 
functional  exasperation  may  entail  visible  augmentation  of  movement, 
the  cause  of  which  is  not  central,  but  lies  in  the  external  manifestation  of 
muscular  over-activity. 

The  antagonistic  gesture  is,  in  some  instances, 
contemporaneous  with  the  wryneck,  although  more 
usually  it  is  not  in  evidence  until  months  or  years  after 
the  distortion  has  become  inveterate. 

1  PIERRE  MARIE  AND  GUILLAIN,  "  Torticolis  mental  avec  mouve- 
ments  des  membres  sup6rieurs  de  nature  spasmodique,"  Soc.  de  neur. 
de  Paris,  April  17,  1902. 


1 82         TICS  AND   THEIR   TREATMENT 

Mental  torticollis  is  characterised  by  remarkable 
chronicity.  "We  have  seen  cases  of  ten  or  fifteen 
years'  duration  and  more.  Temporary  remissions 
have  been  known,  however,  and  alternations  with  other 
tics  or  with  psychical  affections.  At  the  Congress  of 
Limoges,  the  following  case  was  reported  by  Briand : 

As  the  result  of  a  bicycle  accident,  a  young  man  developed  a  torticollis 
which  ordinary  treatment  was  sufficient  to  cure,  and  it  remained  in 
abeyance  until  he  entered  a  government  school,  when  its  place  was  taken 
by  a  tic  of  the  shoulder,  with  twitching  of  the  mouth  and  eye.  At  the 
approach  of  the  annual  vacation  the  tic  disappeared,  and  the  torticollis, 
for  some  simple  reason  or  other,  became  obvious  again.  The  latter  had 
once  more  been  got  under  control  by  the  time  the  holidays  were  over, 
but  on  the  patient's  re-entering  school  the  shoulder  tic  again  manifested 
itself,  and  this  sequence  recurred  several  times.  A  permanent  cure  was 
eventually  effected,  but  he  continued  as  psychasthenic  as  ever. 

In  another  of  Briand's  cases  torticollis  alternated 
with  astasia-abasia,  a  sort  of  "  mental  paraplegia."  The 
patient  could  not  walk  at  all  without  crutches,  or 
without  a  little  minerve,  which  he  used  either  to  steady 
his  gait  or  to  keep  his  head  straight. 

No  doubt  facts  such  as  these  just  given  are  rather 
uncommon,  but  there  is  abundant  reason  for  considering 
mental  torticollis  one  of  the  most  tenacious  and  in- 
tractable of  all  tics. 

TICS   OF    THE    TRUNK 

The  rarity  of  isolated  involvement  of  the  thoracic 
muscles,  and  the  frequency  of  their  inclusion  in  tics 
of  the  neck  and  limbs,  arise  from  the  fact  of  their 
insertion  into  the  bones  of  the  extremities,  and  con- 
sequently conditions  affecting  them  will  be  dealt  with  ir 
another  place.  Omitting  for  the  present  all  reference 
to  the  muscles  of  respiration,  we  have  to  consider  only 
the  vertebral  and  abdominal  groups.  These  pass  into 
activity  in  the  rhythmical  salutation  and  balancing 
movements  so  common  among  idiots,  movements  bear- 


THE  DIFFERENT   TICS  183 

ing  the  most  intimate  analogies  to  the  tics,  though 
their  peculiarity  of  rhythm  justifies  their  separate 
classification. 

Tonic  contractions  that  find  expression  in  attitude 
tics  of  the  body  are  generally  associated  with  tonic 
tics  of  the  neck  and  limbs,  and  in  some  cases  of  mental 
torticollis  the  deformation  they  produce  is  extensive. 

The  material  part  played  by  the  abdominal  muscles 
in  the  function  of  respiration  explains  their  implication 
in  respiratory  tics.  A  curious  case  of  this  kind  has 
been  published  by  Pierre  Janet l : 

A  woman  thirty-two  years  old  had  been  afflicted  for  three  years  with 
a  respiratory  tic  that  consisted  in  imitating  with  the  lips  the  neighing  of 
a  horse,  and  with  a  still  more  extraordinary  tic  of  the  abdominal  parietes. 
She  appeared  to  "  swallow  her  stomach "  ;  in  other  words,  her  abdomen, 
prominent  enough  in  its  ordinary  state,  was  flattened  and  retracted,  and 
the  skin  so  stretched  and  dragged  upwards  that  the  umbilicus  approached 
the  costal  margin.  Just  as  it  seemed  to  be  disappearing,  to  be  "  swallowed," 
relaxation  of  the  abdomen  slowly  took  place,  and  this  procedure  was 
repeated  ten  or  twelve  times  a  minute.  Pressure  on  the  epigastrium 
inhibited  the  abdominal  movement,  but  was  accompanied  by  immediate 
renewal  of  the  neighing,  whereas  with  the  relief  of  the  pressure  the 
sequence  of  events  was  inverted. 

TICS    OF   THE    ARM   AND    OF   THE   SHOULDER 

In  the  upper  extremity  tics  may  affect  the  various 
muscles  of  the  shoulder,  arm,  or  forearm.  Shoulder  tics 
are  of  frequent  occurrence,  and  often  owe  their  origin 
to  the  discomfort  of  a  tight  sleeve  or  of  a  badly  fitting 
collar.  They  are  generally  a  concomitant  of  neck  tics, 
in  particular  of  mental  torticollis. 

In  this  connection  we  may  recall  the  case  of  0.,  and 
supplement  it  by  a  description  of  another — viz.  young  J. 

This  boy  J.  had  always  been  "  nervous,"  and  affected  with 
"  nervous  movements "  of  face  or  limbs.  At  the  age  of  thirteen  years, 
when  playing  in  the  house  one  day,  he  knocked  himself  against  an  open 

1  PIERRE  JANET,  Nevroses  et  idees  fixes,  vol.  i.  p.  311. 


184          TICS  AND    THEIR    TREATMENT 

door  and  bruised  the  shoulder  near  the  outer  end  of  the  left  clavicle.  Three 
or  four  days  later  all  pain  and  discolouration  had  vanished,  and  the  child's 
movements  were  perfectly  unimpeded  again.  His  tics  continued  as  before. 
Two  months  after  this  little  accident  was  over  and  forgotten,  it  was 
remarked  that  at  the  seat  of  the  contusion  there  was  a  slight  swelling, 
quite  painless  and  scarcely  even  uncomfortable,  but  disquieting  enough 
to  the  parents  and  thought  to  require  applications  of  neapolitan  ointment 
and  the  actual  cautery.  This  line  of  treatment  effected  no  alteration  in 
the  local  condition,  but  it  had  other  far-reaching  consequences,  for  the 
boy  noticed  the  anxious  interest  aroused  by  the  singular  exostosis,  and 
began  to  devote  attention  to  it  himself.  From  the  moment  that  his 
parents  manifested  their  apprehension  by  words  of  pity  and  by 
solicitous  examination,  his  tics  developed  a  preference  for  the  left 
shoulder,  though  continuing  to  exhibit  themselves  in  the  face  and  the 
right  arm.  He  would  unexpectedly  elevate  or  depress  his  shoulder,  would 
shrug  it  forwards  or  brace  it  back,  accompanying  the  performance  with 
inclination  of  the  head  or  abduction  of  the  upper  extremity.  He  was  very 
positive  as  to  the  painless  nature  of  his  affection  ;  his  sole  complaint  was  of 
a  certain  stiffness  in  the  joint,  and  at  the  thought  of  it  came  an  impulse 
to  move  the  shoulder  which  there  was  no  resisting.  The  twitching  would 
disappear  for  a  time  for  no  fathomable  reason,  and  reappear  again.  By 
the  exercise  of  a  little  circumspection  he  could  tempprarily  overcome  it, 
and  during  sleep  it  subsided  entirely. 

The  facts— duly  controlled  and  confirmed  by  the  parents — that 
involuntary  shoulder  movements  preceded  not  merely  the  application 
of  the  counter-irritants,  but  the  accident  itself,  and  that  the  unique 
difference  lay  in  the  similarity  of  his  shoulder  tic  to  all  his  other  tics 
before  the  trauma,  and  in  its  marked  preponderance  in  degree  and  frequency 
after,  especially  subsequent  to  the  treatment,  are  of  weighty  diagnostic 
significance.  Plainly  the  injury  and  its  sequelae  did  not  exert  any 
causative  influence  on  the  tic,  and  while  it  is  conceivable  that  the  clavicle 
may  have  been  cracked  and  an  exostosis  ensued,  we  must  repeat  that  the 
pre-existence  of  the  movements  in  question  negatives  the  possibility  of  their 
being  attributable  to  nerve  irritation  from  a  periosteal  overgrowth.  The 
only  effect  which  the  accident  and  its  consequences  had  was  to  intensify 
the  patient's  preoccupation  and  to  determine  the  incidence  of  the  tic. 

By  the  month  of  October,  1900,  the  latter  was  at  its  height,  and  had 
reached  a  state  where  differentiation  of  the  movements  and  of  their 
muscular  counterparts  was  attended  with  no  little  difficulty.  They  could 
be  resolved  into  four  principal  groups,  whereby  the  shoulder  was  raised, 
lowered,  advanced,  or  drawn  back,  respectively.  The  first  of  these 
presented  no  unusual  feature  except  that  with  it  the  head  was  commonly 
inclined  to  the  same  side  ;  but  the  act  of  depression  was  rather  peculiar, 
inasmuch  as  it  was  achieved  by  a  sudden  contraction  of  the  inferior 


THE  DIFFERENT   TICS  185 

muscles  of  the  scapula,  together  with  the  pectoralis,  which  drew  the 
humeral  head  downwards,  elongated  the  capsule,  and  stretched  the 
deltoid  fasciculi  over  it.  The  space  thus  left  between  the  separated 
articular  surfaces  was  partly  filled  in  by  the  neighbouring  ligamentous  and 
muscular  structures.  Anterior  or  posterior  projection  of  the  shoulder  took 
place  at  the  expense  of  an  actual  subluxation,  the  head  of  the  humerus 
bulging  under  the  pectoral  or  the  scapular  muscles.  Each  and  every 
movement  was  accompanied  by  articular  cracking,  sometimes  so  in- 
significant as  scarcely  to  be  pathological,  to  which,  nevertheless,  the  boy 
attached  extravagant  importance  and  devoted  methodical  investigation. 

Ordinary  arm  movements  were,  without  exception,  unimpaired,  nor 
was  any  bony  malformation  discoverable.  The  two  shoulders  were 
practically  symmetrical,  though  the  upper  border  of  the  trapezius  on 
the  left  side  was,  if  anything,  thickened  and  more  prominent  than  its 
fellow,  and  the  same  applied  to  the  left  scapular  muscles.  Horizontal 
extension  of  the  left  arm  revealed  a  slight  tremulousness,  quite  dis- 
tinguishable from  pathological  tremor  and  from  fibrillary  twitching,  and 
wholly  comparable  to  what  is  seen  when,  by  reason  of  a  fracture  or 
otherwise,  a  limb  is  for  a  certain  length  of  time  prevented  from  executing 
movements  of  extension. 

[Beating  or  striking  tics  (the  patient  using  his  own 
fist  against  himself)  arise  from  the  attempt  to  alleviate 
some  insignificant  pain  or  irritation ;  but  tics  of  this 
kind  are  in  their  turn  the  exciting  cause  of  local 
discomfort,  and  so  of  fresh  tics.  In  spite  of  the  obvious- 
ness of  this,  it  is  often  difficult  to  convince  the  patient 
that  his  movements  are  prior,  not  consecutive,  to  the 
unpleasant  sensations.1] 

Finally,  tonic  tics  of  the  upper  extremity  find  ex- 
pression in  attitudes  that  vary  with  the  localisation 
of  the  contraction.  We  have  already  had  occasion  to 
observe  this,  which  is  an  almost  constant  phenomenon 
in  mental  torticollis,  in  the  case  of  young  J.,  in 
Madame  T.,  and  in  N.,  where,  it  will  be  remembered, 
the  all  but  permanent  elevation  of  the  right  shoulder 
seemed  traceable  to  the  habit  of  cutting  stuffs  with  a 
pair  of  large  scissors. 

1  MEIGE  AND  FEINDEL,  "  Remarques  cliniques  et  therapeutiques 
sur  quelques  tics  de  1'enfance,"  Journ.  de  neurologie,  1904. 


1 86          TICS  AND    THEIR    TREATMENT 

TICS    OF    THE    HANDS-SCRATCHING    TICS 

Scratching  movements  are  infinite  in  their  variety, 
and  since  the  co-operating  muscles  vary  in  each  case, 
the  question  of  muscular  localisation  is  of  secondary 
interest. 

The  object  in  view  in  the  act  of  scratching  is  relief 
from  some  such  source  of  cutaneous  irritation  as  a 
pimple,  an  abrasion,  a  burn,  the  bite  of  an  insect,  etc., 
and  so  long  as  the  cause  persists,  the  function  is  being 
rationally  exercised ;  but  to  persevere  mechanically, 
involuntarily,  immoderately,  in  the  absence  of  pruritus 
or  of  other  paraBsthesise,  is  a  sign  that  the  functional 
act  is  growing  into  a  tic.  Innumerable  tics  are  thus 
developed,  and  they  are  intimately  associated  with 
biting  tics. 

S.  passes  his  hand  every  instant  over  his  forehead, 
0.  over  his  eyes,  T.  over  her  lips,  P.  over  his 
moustache,  young  J.  over  his  budding  whiskers,  etc., 
etc.  These  elementary  tics  are  scarcely  more  than 
stereotyped  acts,  and  may  maintain  the  semblance 
indefinitely,  though  there  is  also  the  likelihood  of  their 
becoming  immeasurably  more  pronounced. 

M.  scratches  his  lips  with  his  nails  till  they  are 
bleeding ;  E.  suffers  from  a  facial  tic,  and  scrapes 
at  his  forehead  and  temples  to  such  an  extent  that 
his  complexion  is  perpetually  blooming  with  a  crop  of 
little  bleeding  excoriations ;  in  some  places,  as  a 
result  of  ceaseless  rubbing  and  tapping,  the  skin  is 
thickened  and  discoloured — a  condition  that  might  be 
known  as  "  scratchers'  corns."  Madame  W.  used  to 
tear  at  her  toe  nails  with  her  fingers  whenever  she  had 
retired  for  the  night ;  and  at  the  present  time,  as  a 
result  of  incessantly  passing  a  fine  gold  chain  between 
the  pulp  of  her  fingers  and  the  nails,  she  has  succeeded 
in  half  detaching  the  latter  from  their  bed. 


THE   DIFFERENT   TICS  187 

A  case  reported  by  Raymond  and  Janet l  is  one  of 
unusual  severity. 

A  little  girl  ten  years  old  was  covered  from  head  to  foot  with  scabs  and 
sores,  some  of  which  on  the  body  were  several  centimetres  in  diameter  and 
looked  very  ugly.  These  she  had  contrived  to  inflict  on  herself,  in  spite  of 
every  precaution  and  admonition.  It  appeared  that  successive  attacks  of 
measles  and  of  whooping-cough  at  the  age  of  five  had  entailed  long  rest  in 
bed,  and  had  been  followed  by  a  tardy  convalescence,  in  the  course  of 
which  the  development  of  a  few  pimples  on  the  forehead  was  the  signal 
for  her  to  commence  scratching  them  and  any  other  part  of  her  body 
where  there  was  the  least  discomfort,  or  where  the  skin  was  at  all 
roughened.  This  merciless  self-mutilation  ended  in  the  production  of 
large  and  painful  excoriated  areas  j  nevertheless  a  tic  had  sprung  from 
the  habit,  and  it  remained  inveterate. 

Another  analogous  case  is  quoted  by  the  same 
observers 2 : 

In  this  instance,  apart  from  the  obvious  existence  of  a  confirmed  tic, 
the  patient  had  a  curious  look  about  the  eyes  which  a  nearer  glance 
showed  was  caused  by  complete  absence  of  the  eyelashes.  He  had  a 
trick  when  speaking  or  talking  of  lifting  his  right  hand  and  running 
his  finger  carefully  along  the  margin  of  the  lids,  and  if  it  encountered 
.an  eyelash  projecting  beyond  the  skin,  he  promptly  plucked  it  out. 
The  endless  repetition  of  this  toilette  rendered  the  eyelids  barren  of 
lashes. 

TICS    AND    WRITING 

Are  writing  tics  to  be  recognised  ? 

Tricks  and  turns  of  writing,  however  ridiculous, 
involuntary,  and  ingrained  they  be,  scarcely  deserve 
to  be  called  tics.  Those  nourishes  and  ornaments  that 
some  people  take  delight  in  adding  to  their  letters  can 
no  more  be  considered  the  expression  of  a  pathological 
state  than  the  superabundant  gestures,  the  redundant 
words,  the  exuberant  mimicry,  of  which  others  are  so 
prodigal.  They  are  simply  modes  of  exteriorisation 
peculiar  to  the  individual,  and  if  in  their  superfluity 

1  RAYMOND  AND  JANET,  Nevroses  et  idees  fixes,  vol.  ii.  p.  390. 
3  Id.,  loc.  at.  p.  388. 


188          TICS  AND    THEIR    TREATMENT 

and  excess  they  go  beyond  the  strict  requirements  of 
the  case,  still,  they  are  only  mannerisms  of  writing  or 
of  speech.  Their  manifestation  is  rigorously  dependent 
on  the  performance  of  some  function,  and  is  not  pre- 
ceded by  an  imperious  need  of  execution. 

More  akin  to  the  tics  is  stereotypy  of  written 
language,  so  common  an  appanage  of  mental  disease. 
The  term  is  intended  to  include  such  habits  as  repeti- 
tion of  a  particular  formula,  underlining  of  words, 
constant  use  of  hyphens  in  the  same  way,  writing  of 
certain  pages  in  a  hand  differing  from  the  rest  of  the 
manuscript.  Seglas1  has  done  excellent  work  in  the 
analysis  and  interpretation  of  these  troubles.  One  of 
his  patients  used  every  week  to  write  letters  bearing 
the  same  complicated  address,  and  signed  invariably 
with  the  following  rigmarole : 

De  Senez  de  Mesange,  great  Prince  Napoleon,  great  Prince  of 
the  Blood  Royal  and  Imperial  of  the  Universe,  great  Admiral,  great 
Marshal  of  my  armies,  .  .  .  great  Procurator  of  the  Republic,  Royal 
and  Imperial,  great  President  of  the  Republic,  Royal  and  Imperial, 
great  Pope,  great  Duke,  great  King,  great  Emperor — Jupiter,  Louis  XIV. 
and  Louis  XV. 

Another  would  write  after  almost  every  sentence : 

Dieu  et  son  Jroit,  let  him  be  cursed  in  all  that  is  most  cursed  qui 
mal  y  pense. 

This  was  a  sort  of  exorcism,  a  cabalistic  formula 
enabling  the  persecuted  unfortunate  to  defend  herself 
against  the  wiles  of  the  evil  spirit. 

A  tic  of  writing,  however,  is  of  a  totally  different 
nature.  He  who,  without  pen  or  pencil,  is  constrained 
by  irrepressible  impulse  to  go  through  the  movements 
of  writing  with  his  fingers,  convulsively,  impetuously ; 
and  he  who,  without  rhyme  or  reason,  feverishly  traces 
characters  utterly  at  variance  with  the  ideas  he  would 

1  SEGLAS,  Les  troubles  de  langage  chez  les  aliencs,  Paris,  1892. 


THE  DIFFERENT   TICS  189 

express,  are  alike  subjects  of  a  writing  tic.  Of  the 
former,  we  know  no  characteristic  example,  while  in 
the  latter  case  the  study  of  the  phenomenon  would 
lead  us  too  far  into  the  realm  of  automatic  writing 
and  graphic  impulsions.  We  must  content  ourselves 
with  recalling  its  occurrence  in  an  undeveloped  form 
in  the  case  of  0. 

Among  those  who  are  affected  with  tics,  disorders 
of  writing  are  very  infrequent,  even  where  the  tic's 
exhibition  is  displayed  in  the  upper  extremities.  One 
of  the  distinctive  features  of  tics,  in  fact,  is  the  brevity 
of  the  interruption  they  cause  in  the  performance  of 
any  voluntary  act  on  the  part  of  the  patient.  Tics  of 
arm  or  hand  effect  but  little  modification  of  his  writing. 
He  is  rarely  taken  aback  by  his  tic's  convulsive 
demonstration.  He  can  permit  the  co-existence,  on  a 
perfect  understanding,  of  two  automatic  acts,  normal 
and  abnormal,  writing  and  tic. 

One  of  Guinon's  patients  was  wont  to  proceed  in  the  following  way  : 
if  asked  to  write,  he  would  lean  on  the  table,  pick  up  his  pen,  and 
just  as  it  was  about  to  touch  the  paper,  make  several  little  movements 
of  circumduction  with  his  right  hand,  as  a  child  does.  Thereafter, 
he  would  sometimes  pass  on  at  once  to  trace  the  letters  ;  at  other  times  he 
would  have  to  grind  his  teeth,  contort  the  right  half  of  his  face,  put  out 
his  tongue,  pucker  his  nose,  or  dip  his  pen  spasmodically  into  the  ink  ten 
consecutive  times — ejaculating  ahem  !  ahem  !  the  while — before  being  able 
to  commence.  He  would  often  cease  altogether,  to  make  one  or  two 
grimaces,  or  to  wave  his  hand  about.  As  far  as  the  actual  writing 
was  concerned,  its  distinctness  and  evenness  were  no  less  praiseworthy 
than  its  style  and  content,  and  though  a  glance  at  his  gesticulations 
led  one  to  expect  blots  and  irregularities  in  his  manuscript,  he  conducted 
his  task  with  assurance  and  correctness. 

Of  course,  if  the  tic,  whatever  it  be,  exceed  a  certain 
limit  of  frequency  and  violence,  accurate  writing  may 
amount  almost  to  a  physical  impossibility,  in  which 
case  the  patient  usually  discontinues,  although  if  called 
on  to  exercise  his  will  he  can  always  pen  a  few  words 


190         TICS  AND    THEIR    TREATMENT 

and  even  a  few  lines.  However  this  may  be,  the  spots 
and  scrawls  and  zigzags  and  shaky  cramped  characters 
we  associate  with  such  organic  affections  as  tabes, 
Friedreich's  disease,  paralysis  agitans,  etc.,  are  wholly 
exceptional  in  the  case  of  tic. 

While,  then,  disturbances  of  the  function  of  writing 
are  seldom  ascertainable  in  those  who  tic,  we  have 
convinced  ourselves  on  more  than  one  occasion  of  the 
truth  of  the  converse,  that  the  exercise  of  the  faculty 
is  sometimes  intimately  combined  with  the  evolution 
of  tics  of  neck  and  shoulder. 

S.  dated  his  mental  torticollis  from  the  time  when 
he  used  to  copy  figures  for  several  hours  a  day.  As  a 
matter  of  fact,  he  wrote  an  excellent  hand,  and  ex- 
perienced no  difficulty  in  performing  the  necessary 
movements,  but  continued  writing  increased  the  rotation. 
N.'s  torticollis  was  the  sequel  to  long  spells  of  office 
work,  during  which  he  never  laid  down  his  pen.  In 
the  case  of  L.,  the  wryneck  and  the  convulsions  of  the 
right  arm  were  preceded  by  a  sort  of  writers'  cramp  of 
the  right  hand,  and  subsequently  of  the  left. 

In  the  accompanying  instance,  the  development  of 
which  one  of  us  has  had  the  opportunity  of  observing, 
the  appearance  of  the  torticollis  was  at  first  confined  to 
occasions  of  writing,  but  gradually  it  came  into  evidence 
with  other  arm  actions,  and  eventually  established  itself 
in  a  permanent  fashion. 

P.,  fifty  years  old,  occupies  a  responsible  position  in  a  big  railway 
company,  is  director  in  a  large  office,  and  performs  his  duties  with 
peculiar  conscientiousness  and  zeal.  Naturally  an  emotional  man,  he 
was  much  distressed  by  an  unusually  sad  family  bereavement  about  the 
middle  of  1900,  which  coincided  with  a  period  of  great  overwork.  As 
he  was  obliged  every  day  to  arrange  innumerable  papers  and  affix  his 
signature  to  them,  he  began  to  notice  that  each  time  he  wrote  his  name 
his  head  turned  to  the  right  involuntarily,  and  he  felt  a  sensation  of  dis- 
comfort in  the  neck  and  right  shoulder.  He  tried  to  remedy  the  faulty 
position  by  holding  his  chin  with  his  left  hand  ;  nevertheless,  in  the 


THE  DIFFERENT   TICS  191 

course  of  the  next  few  months  the  movement  began  to  assert  itself  not 
merely  as  he  wrote  his  signature,  but  also  when  he  cut  his  food  at  table, 
or  sharpened  a  pencil,  or  trimmed  his  finger  nails. 

October  14,  1901. — Whenever  P.  proceeds  to  write,  his  head  is 
immediately  rotated  to  the  right  and  maintained  in  that  attitude  by 
successive  contractions.  Simultaneously,  the  right  side  of  the  face  is 
distorted  by  a  grimace,  the  right  eye  blinks,  and  the  right  corner  of 
the  mouth  is  drawn  down  by  a  strong  effort  of  the  platysma.  The 
state  of  affairs  is  unaltered  so  long  as  he  is  handling  a  pen,  though, 
curiously  enough,  his  caligraphy  itself  is  flawless.  The  more  firmly  he 
grasps  his  pen,  the  more  violent  the  spasms  ;  the  substitution  of  a 
pencil  abates  them  somewhat,  as  does  writing  on  the  floor  with  a 
cane,  while  if  he  traces  letters  in  the  air  in  front  of  him  with  his 
finger,  they  do  not  occur  at  all.  When  both  hands  are  occupied  in 
writing,  the  head  still  turns  to  the  right. 

He  was  advised  to  incline  his  head  on  his  right  shoulder  as  he 
wrote,  and  to  force  his  right  sternomastoid  to  contract,  in  carrying 
out  which  instructions  he  managed  to  form  several  hooks  and  rods 
correctly  without  any  torticollic  movement,  and  was  both  elated  at 
the  success  of  the  experiment  and  dejected  by  the  thought  of  his 
infirmity.  Accordingly  all  writing  was  prohibited,  all  signature  making 
reduced  to  a  minimum,  and  he  was  recommended  a  simple  pencil 
exercise,  to  be  performed  with  slowness  and  deliberation  while  the 
head  was  kept  in  the  position  just  mentioned.  Identical  rules  were 
to  be  observed  when  eating,  etc.,  and  a  tepid  bath  was  prescribed  night 
and  morning. 

October  21. — Some  improvement  has  taken  place.  The  patient  is  less 
uneasy  and  less  discouraged.  Dissociation  of  the  movements  of  writing 
into  their  component  parts  and  isolated  execution  of  each  are  accomplished 
admirably  at  the  first  trial,  less  well  the  second,  and  at  the  third,  rotation 
recommences.  Fatigue  rapidly  increases,  and  P.  sinks  again  into  im- 
patience, enervation,  and  despair.  Occasionally  his  anguish  is  so  extreme 
he  is  covered  with  perspiration  even  after  the  most  elementary  pencil 
drill,  and  is  forced  to  mop  his  brows. 

November  21. — Improvement  is  maintained.  He  can  now  write 
various  letters  and  short  words  at  his  ease,  though  he  still  feels  uncomfort- 
able in  anything  requiring  a  more  sustained  effort.  Otherwise,  he  is 
conscious  of  greater  control  over  his  head. 

December  15. — The  amelioration  has  not  persisted.  While  he  was 
paying  a  visit  to  the  barber's,  and  having  his  hair  cut,  rotation  to  the 
right  began  again,  and  when  lifting  his  hat  in  the  street  to  salute  a 
friend,  he  repeated  the  movement.  At  table,  too,  he  noticed  it  as  he  was 
in  the  act  of  bringing  his  glass  to  his  mouth.  P.  is  consequently  upset, 
and  often  plunged  into  tears. 


192          TICS  AND    THEIR    TREATMENT 

December  24. — The  patient's  condition  is  more  than  ever  deplorable. 
On  the  slightest  provocation — indeed,  on  no  provocation  at  all — furious 
torsion  movements  force  the  head  backwards  and  to  the  right,  while 
the  right  shoulder  rises. 

Complete  rest  in  bed  was  ordered,  yet  after  two  or  three  days  of  this 
repose  the  torticollis  manifested  itself  even  in  the  recumbent  position.  As 
a  result,  he  was  quite  unnerved  and  talked  of  suicide.  Another  physician 
called  in  consultation  agreed  with  what  had  been  done,  confirmed  the 
integrity  of  all  the  reflexes,  including  the  plantars,  and  recommended 
a  course  of  electricity. 

January  20,  1902. — There  has  been  no  further  change.  P.  stays  abed 
all  morning,  inventing  endless  arrangements  of  pillows  and  dictionaries  to 
prop  his  head.  When  he  goes  out  for  a  walk,  he  turns  up  the  collar  of 
his  coat  and  leans  his  head  on  the  point  of  it. 

January  27. — The  electrical  treatment  has  been  relinquished.  He 
has  also  taken  one  douche  at  a  hydrotherapeutic  establishment,  but 
expressed  his  dissatisfaction  and  vowed  never  to  return.  He  then  departed 
to  undergo  a  "  water  cure "  in  the  country,  since  when  he  has  vanished 
entirely  from  observation. 

More  than  once  we  have  had  occasion  to  notice  that 
the  degree  and  extent  of  such  neck  and  arm  convulsions 
as  are  provoked  or  exaggerated  by  the  act  of  writing 
vary  with  the  level  at  which  the  patient  has  to  write. 
"With  elevation  of  the  arm  the  movements  are  weak  and 
easily  mastered ;  conversely,  lowering  of  the  arm  aug- 
ments them  in  a  marked  manner.  We  repeat,  however, 
that  in  all  these  cases  the  handwriting  itself  is  not 
interfered  with. 

It  is  quite  otherwise  with  writers'  cramp,  the  so- 
called  "  graphospasm  "  or  "  mogigraphia."  This  con- 
dition is  purely  and  exclusively  a  disorder  of  the 
function  of  writing,  depending  for  its  exhibition 
on  the  exercise  of  this  function,  else  is  its  existence 
concealed.  For  this  reason  it  ought  to  be  differentiated 
from  the  tics,  although,  by  its  development  in  obvious 
neuropathic  or  psychopathic  subjects,  it  is  closely  linked 
to  them. 

One  of  Oppenheim's  cases  was  a  lady  whose  husband 
suffered  from  paralysis  agitans ;  in  her  case,  fear 


THE  DIFFERENT   TICS  193 

of  becoming  affected  with  the  same  disease  led  to  the 
development  of  writers'  cramp.  Sometimes  it  occurs 
in  families,  and  it  may  be  a  concomitant  of  genuine 
tics.  In  spite  of  the  affinity  between  these  two  sorts 
of  functional  disturbance,  we  do  not  feel  it  incumbent 
on  us  to  enter  on  a  detailed  study  of  scriveners'  palsy  in 
this  place. 


TICS   OF  THE    LOWER    EXTREMITIES-WALKING    AND 
LEAPING    TICS 

Tics  of  the  lower  limbs  are  infrequent,  and  seldom 
isolated.  One  of  the  most  habitual  of  these  is  the 
"  kicking  tic."  Sometimes  one  leg  knocks  against  the 
other,  as  in  O.'s  case,  or  it  is  kicked  out  in  front,  or  to 
the  side,  or  even  backwards,  after  the  manner  of  a  horse. 
Tonic  convulsions  of  the  leg  muscles  have  been  ob- 
served to  give  rise  to  phenomena  analogous  to  tonic 
tics.  Tonic  contractions  restricted  to  a  particular  muscle, 
or  group  of  muscles,  and  accompanied  by  relaxation  of  the 
antagonists,  have  been  christened  by  Ehret l  "  habit  con- 
tractures  "  and  "  habit  paralyses."  Their  characteristic 
feature  is  the  fact  of  the  contracture  being  voluntary 
in  origin.  For  instance,  an  individual  wounds  the  inner 
margin  of  hisfoot,  and  learns  to  escape  the  pain  by  throw- 
ing his  weight  on  the  outer  side.  Voluntary  contraction 
of  the  adductors  of  the  foot  passes  gradually  into  an  in- 
voluntary stage,  giving  place  to  spasmodic  contraction, 
and  the  simultaneous  inactivity  of  the  antagonists — in 
this  case  the  peronei — leads  ultimately  to  their  atrophy. 

In  Ehret's  view  the  fact  of  loss  of  volitional  control 
argues  the  psychical  nature  of  the  affection,  and  a 
similar  opinion  is  held  by  Thiem,  Jacoby,  and  Wolff, 
who  attribute  the  analogous  cases  they  report  to  a 
sort  of  traumatic  neurosis  in  which  the  psychical 
1  EHRET,  Archivf.  Unfallheilkunde,  1898,  p.  32. 

13 


194          TICS  AND    THEIR    TREATMENT 

element    is    preponderant.     Needless    to    remark,    the 
patients  in  question  were  not  suffering  from  hysteria. 

In  this  connection  ought  to  be  recalled  the  cases 
described  by  Raymond  and  Janet  *  under  the  title  of 
"  tics  of  the  foot." 

The  first  was  a  woman  thirty-seven  years  old,  who  as  she  walked  used 
slightly  to  invert  her  left  foot,  forcibly  dorsiflex  the  great  toe,  and  separate 
the  remaining  toes  widely  one  from  the  other.  Notwithstanding  its  painful 
nature,  the  condition  had  persisted  for  seven  years,  and  had  originated 
in  a  very  interesting  way.  She  happened  to  be  undergoing  a  course 
of  mercurial  inunction  at  the  same  time  as  she  was  troubled  with  a 
corn.  The  idea  struck  her  that  perhaps  the  application  of  the  ointment 
to  the  corn  might  prove  efficacious,  but  while  trimming  the  latter  some 
days  later,  she  had  the  misfortune  to  cut  herself.  Dread  of  the  possible 
evil  effects  of  the  injury  was  followed  on  the  morrow  by  an  accession 
of  cramps  in  the  foot,  the  continuance  of  which  led  to  the  deformity  that 
ever  since  had  made  walking  a  misery. 

The  other  patient  was  a  young  man  twenty  years  of  age,  whose  gait 
used  to  be  arrested,  after  a  walk  of  ten  minutes,  by  sudden  and  vigorous 
plantar  flexion  of  his  right  toes.  Momentary  repose  sufficed  to  make  the 
spasm  disappear,  but  it  constantly  recurred. 

Re-education  and  psychotherapy  effected  a  cure  in 
each  instance,  so  that  their  psychical  nature  cannot  be 
called  in  question,  nevertheless  the  painful  character  of 
the  affections  must  not  be  forgotten,  and  since  the  occa- 
sions of  their  manifestation  were  confined  to  the  act  of 
walking,  they  correspond  rather  to  "functional"  or  "  pro- 
fessional cramps."  In  any  case,  they  cannot  be  con- 
founded with  the  painful  cramps  of  the  calf  muscles 
that  characterise  certain  toxaemias  and  infections 
(alcoholism,  cholera,  etc.). 

On  the  other  hand,  there  can  be  no  doubt  of  the 
existence  of  definite  tics  of  walking — widely  varying 
functional  derangements  of  tonic  or  clonic  type,  distin- 
guished by  the  unexpected  interruption  of  ambulatory 
rhythm. 

1  RAYMOND  AND  JANET,  "Note  sur  deux  tics  de  pied,"  Nowv.  icon, 
de  la  Salpetriere,  1899,  p.  353. 


THE  DIFFERENT   TICS  195 

We  have  met  with  a  patient  (says  Guinon)  who  would  abruptly  halt 
and  bend  his  knees  as  though  he  had  just  received  a  violent  blow 
on  the  hock  for  which  he  was  unprepared.  To  see  him,  one  would 
have  thought  he  was  about  to  sink  to  the  ground. 

Such  tics  of  genuflexion  are  not  particularly  un- 
common. Oddo l  has  recently  recorded  a  very  instructive 
example,  whose  pathogeny  he  has  been  at  pains  to 
elucidate. 

A  little  girl,  Th.,  ten  years  of  age,  takes  four  or  five  perfectly 
normal  paces  when  she  starts  to  walk,  then  bends  down  quickly  to  the 
right,  flexing  her  knee  to  an  acute  angle  and  inclining  her  trunk  forward 
with  the  deflection  of  her  pelvis,  just  as  a  child  whose  genuflexion  in 
front  of  an  altar  has  become  mechanical  by  repetition.  The  performance 
is  sometimes  so  altogether  sudden  that  Th.  actually  falls  .on  to  her  right 
side.  One  striking  feature  of  the  case  is  that  if  she  makes  a  tour  of  the 
room  in  order  to  be  observed  at  leisure,  the  inclination  never  fails  to 
occur  at  exactly  the  same  point  in  the  circuit — namely,  when  she  is  opposite 
the  observer.  It  is  useless  formally  to  interdict  her  from  this  routine, 
for  before  one  has  time  to  notice  any  irregularity  in  the  gait  her  knee 
suddenly  flexes  at  the  bidding  of  an  invincible  impulse,  and  a  moment 
later,  without  any  deviation  from  her  path,  she  has  resumed  her  rhythmical 
step  round  the  apartment. 

This  movement  is  not  her  only  one,  however.  While  she  lies  in  bed 
she  can,  by  flexing  her  thigh  on  her  pelvis,  crack  her  joints  loud  enough 
to  be  heard,  and  when  she  has  been  up  a  little  while  the  same  action  is 
exhibited.  The  absence  of  these  cracking  sounds  during  ordinary 
walking,  and  their  occurrence  in  the  act  of  genuflexion,  very  properly 
explain,  as  Oddo  thinks,  the  origin  of  the  tic.  It  seems  that  the  articu- 
lations at  hip  and  knee  on  the  right  side  were  affected  as  the  result 
of  successive  attacks  of  scarlatina  and  diphtheria  two  years  ago,  which 
necessitated  a  prolonged  sojourn  in  bed,  and  were  accompanied  with 
severe  pain.  It  is  interesting  to  note  that  the  tic  made  its  appearance  only 
after  the  latter  had  considerably  subsided. 

Raymond  and  Janet  *  have  reported  the  case  of  a  young  woman  who 
fell  on  her  knees  every  few  paces,  rising  again  with  facility  and  taking  a 
few  more  steps,  to  come  down  on  her  knees  once  more  with  a  loud 
noise.  She  never  did  herself  any  harm,  however,  and  for  that  matter  the 
accident  never  occurred  on  a  staircase  or  in  a  unsuitable  or  dangerous 
spot. 

1  ODDO,  "  Tic  de  la  genuflexion,"  Marseille  medical^  March  15    1902. 

2  RAYMOND  AND  JANET,  Nevroses  et  idees  fixes,  vol.  ii.  p.  391. 


196          TICS  AND    THEIR    TREATMENT 
Leaping  tics  are  met  with  also. 

Sometimes  when  walking,  but  more  usually  when  standing  quietly, 
according  to  Guinon,  the  patients  make  little  jumps  or  leaps  in  their  place, 
looking  rather  as  if  they  were  dancing  than  really  springing  into  the  air. 
Some  actually  bound  along,  others  run  for  a  yard  or  two. 

Still  more  bizarre  and  complex  tics  have  been 
described,  in  particular  by  Gilles  de  la  Tourette.  One 
patient  used  to  commence  to  run,  then  kneel  suddenly, 
then  rise  with  equal  abruptness.  Another  was  in 
the  habit  of  stooping  down,  as  if  to  pick  something 
off  the  ground,  and  smartly  rising  again. 

The  kinship  of  these  and  other  similar  conditions 
to  the  tics  is  undeniable,  and  such  seems  to  be  the  case 
with  the  yet  more  extraordinary  phenomena  of  jumping 
in  Maine  (Beard),  latah  among  the  Malays  (O'Brien), 
tnyriachit  in  Siberia  (Hammond).  All  these  affections 
show,  among  others,  this  peculiarity — that  unexpected 
contact  produces  a  spring  (Guinon). 

In  a  recent  thesis  Bamisiray  has  depicted  the 
dancing  mania  (ramaneniaTia)  of  Madagascar,  a 
condition  allied  to  the  latah  of  the  Dutch  Indies,  but 
more  intimately  connected  with  hysteria,  perhaps,  and 
with  the  saltatory  choreas,  the  saltatory  cramps  of 
Bamberger,  St.  John's  and  St.  Guy's  dance,  tarentism, 
etc.  The  exact  nature  of  these  convulsive  disorders 
is  still  sub  judice,  but  in  any  case  they  present  more 
than  a  mere  resemblance  to  the  tics. 


SP1TTINQ,   SWALLOWING,   AND  VOMITING  TICS— TICS 
OF  ERUCTATION  AND  OF  WIND   SUCKING 

In  some  tics  the  palatal  muscles  are  found  to 
contract,  but  this  contraction  must  not  be  confused 
with  the  spasmodic  twitches  of  the  same  muscles 
associated  with  facial  spasm  and  due  to  central  or 


THE  DIFFERENT   TICS  197 

peripheral  irritation  of  the  seventh  nerve.  One  of  us 
has  had  occasion  to  observe  an  excellent  case  in  point  in 
a  young  man  afflicted  with  spasm  of  the  orbicularis  and 
zygomatics  on  the  right  side,  in  whom  synchronous 
displacement  of  the  uvula  occurred  with  each  twitch. 
The  extreme  abruptness  and  rapidity  of  the  muscular 
discharges,  the  inadequacy  of  voluntary  effort  to  check 
them,  the  absolute  uselessness  of  prolonged  and  syste- 
matic treatment,  left  no  doubt  as  to  the  accuracy  of 
the  diagnosis. 

The  occurrence  of  palatal  spasm  in  intracranial  lesions 
has,  of  course,  been  recognised — in  cerebellar  tumour 
(Oppenheim),  in  epidemic  cerebrospinal  meningitis,  in 
aneurism  of  the  vertebral  artery  (Siemerling  and 
Oppenheim).  It  is  occasionally  associated  with  the 
emission  of  clucking  sounds,  and  with  convulsive 
action  of  hyoid  and  tongue  muscles.  In  such  cases 
the  distinction  between  a  tic  and  a  spasm  is  not  always 
easy  to  establish.  "We  may,  however,  readily  recognise 
that  we  are  dealing  with  the  former  if  the  contractions 
of  tongue,  palate,  and  larynx  are  contemporaneous 
with  the  execution  of  a  functional  act,  such  as  ex- 
pectoration. 

Among  those  who  labour  under  obsessions,  tics  of 
expectoration  are  well  known.  One  of  Guinon's 
patients,  while  making  forced  expirations,  used  to 
bring  his  hand  up  over  his  mouth  convulsively  as 
though  he  were  afraid  of  spitting  on  some  one  in  his 
neighbourhood. 

A  case  of  S^glas',  from  whom  stigmata  of  hysteria  were  absent,  was 
possessed,  among  other  things,  with  the  fear  of  having  swallowed  certain 
objects,  such  as  pins,  knives,  etc.  The  obsession  eventually  became  so 
vivid  and  so  intense  at  certain  moments,  that  it  began  to  be  accompanied 
with  a  sensation  as  of  a  foreign  body  arrested  in  the  oesophagus,  and 
the  anguish  thus  created  revealed  itself  by  various  reactions,  one  of  which 
consisted  in  excessive  salivation  and  ceaseless  expectoration,  entailing  the 
carrying  about  and  use  of  numbers  of  handkerchiefs. 


198         TICS  AND    THEIR   TREATMENT 

It  is  scarcely  possible  for  the  mechanism  of  degluti- 
tion, the  orderly  succession  of  muscular  contractions, 
to  be  interfered  with  by  the  will,  but  increased  frequency 
of  these  movements  may  constitute  an  abnormality. 
Hartenberg's l  case  of  deglutition  tic  was  characterised 
by  a  continual  desire  of  swallowing  saliva ;  the  patient, 
it  is  true,  was  an  hysteric. 

E-ossolimo2  has  called  attention  to  what  he  distin- 
guishes as  amyotaxic  troubles  of  deglutition,  a  dysphagia 
of  which  three  types,  motor,  sensory,  and  psychic,  may 
be  specified.  Cases  of  the  last  form  had  already  been 
described  by  Bechterew.3  The  patient  either  suffers 
from  a  genuine  obsession,  or  is  ever  at  the  mercy  of 
an  involuntary  or  even  an  unconscious  dread  of  choking 
as  he  eats,  a  dread  with  which  he  is  powerless  to 
cope,  though  in  the  case  of  others  the  phobia  and  the 
dysphagia  may  alike  be  intermittent.  In  the  majority 
of  instances  there  are  grave  hereditary  or  personal 
neuropathic  antecedents. 

Some  people  are  afflicted  with  eructations  so  con- 
tinual that  they  amount  to  tics.  One  of  us  is  acquainted 
with  a  family  several  of  whose  members  present  this 
peculiarity  in  different  degrees,  yet  none  of  them 
suffers  from  hysteria. 

Otto  Lerch4  has  published  a  case  of  multiple  tics, 
among  which  may  be  enumerated  opening  and  closing 
the  eyes,  rolling  of  the  ocular  globes,  tilting  back 
of  the  head,  with  instantaneous  recovery  of  position, 
inclination  of  the  whole  trunk  to  right  or  left — each 
and  all  of  which  movements  are  frequently  attended, 

1  HARTENBERG,  "  Tic  de  deglutition  chez  un  hysterique,"  Rev.  de 
psychologic,  1899,  p.  175. 

1  ROSSOLIMO,  "  Ueber  Dysphagia  amyotactica,"  Neurolog.  Centralb. 
1901,  Nos.  4,  5,  6. 

3  BECHTEREW,      "  Ueber      die     psychischen     SchluckstOrungen," 
Neurolog.  Centralb.  1901,  p.  642. 

4  LERCH,  "  Convulsive  Tics,"  American  Medicine,  Nov.  2,  1901. 


THE  DIFFERENT   TICS  199 

especially  at  night  and  in  the  morning,  by  profound 
eructations. 

Of  course,  the  prominent  place  occupied  by  these 
signs  in  hysteria  is  well  recognised :  the  demonologues 
of  old  regarded  them  as  an  index  of  the  departure  of 
the  devils  that  dwelt  in  the  possessed.  In  a  case  of 
hysteria  that  came  under  the  notice  of  Raymond  and 
Janet,1  a  general  tremuiousness  of  the  whole  body  was 
replaced  by  a  chorea  of  the  right  arm,  which  in  its  turn 
was  succeeded  by  the  perpetual  emission  of  sonorous 
eructations.  In  another  instance 2  inspiratory  hiccoughs 
and  expiratory  eructations  co-existed.  A  similar  ex- 
ample is  cited  by  Cruchet  in  his  thesis. 

In  the  same  category  of  facts  are  included  those  to 
which  the  name  of  aerophagic  tic  has  been  applied. 
Various  cases  have  been  narrated  by  Pitres  and  by 
Seglas,3  the  latter  of  whom,  in  a  remarkably  complete 
analysis  of  the  condition,  has  demonstrated  its  identity 
with  the  tics,  and  written  very  instructive  commentaries 
on  his  observations. 

I  was  consulted  (says  Seglas)  by  a  man  thirty-four  years  of  age,  who 
was  sent  to  me  as  a  hypochondriacal  neurasthenic.  No  sooner  had  he 
entered  my  consulting-room  than  I  was  astonished  to  find  he  was  giving 
vent  to  repeated  sonorous  eructations  at  very  brief  intervals.  His  story 
was  to  the  effect  that  several  weeks  previously  he  had  been  suddenly 
seized  in  the  middle  of  a  meal  by  a  sort  of  vertigo,  and  had  lost  conscious- 
ness. A  consideration  of  subsequent  events  made  it  more  than  probable 
that  he  had  had  an  ictus  ;  the  patient,  however,  was  for  no  apparent 
reason  persuaded  that  he  had  been  poisoned  by  badly  cooked  food,  and 
from  that  moment  became  despondently  preoccupied  with  the  state  of 
his  stomach.  A  few  days  later  the  eructations  made  their  appearance. 

A  closer  examination  very  soon  dispelled  the  idea  of  their  gastric 
origin,  seeing  that  the  digestive  functions  were  in  every  respect  normal, 
whereas  the  symptom  in  question  occurred  at  any  moment,  independently 

1  RAYMOND  AND  JANET,  loc.  tit.  vol.  ii.  p.  35. 

2  Ibid.  p.  357. 

3  SEGLAS,    "  Paralysie    g6n6rale    et    tic    aerophagique,"    Semaine 
medicale,    1899,  p.  9. 


200         TICS  AND   THEIR   TREATMENT 

of  the  stage  of  digestion,  and  the  gases  evolved  were  absolutely  inodorous. 
On  the  other  hand,  one  could  easily  satisfy  oneself  that  the  eructations 
were  preceded  by  an  inspiratory  effort  and  by  two  or  three  very  obvious 
movements  of  deglutition,  accompanied  by  a  low,  rumbling,  pharyngeal 
noise,  and  followed  almost  immediately  by  the  expulsion  of  gas.  Their 
reproduction  several  times  a  minute  was  spasmodic  in  character  and 
irregular  in  rhythm,  and  continued,  it  might  be,  for  hours. 

Of  this  series  of  phenomena  the  patient  had  conscious  knowledge  only 
of  the  last — viz.  the  eructations — and  affirmed  their  involuntary  nature 
and  his  desire  to  be  rid  of  them. 

The  influence  exerted  on  them  by  various  circumstances  is  worthy 
of  notice.  Any  emotion,  or  any  reference  on  the  part  of  the  patient  to 
the  condition  of  his  stomach,  tended  to  exaggerate  them,  while,  inversely, 
it  was  remarked  by  his  wife  that  the  distraction  of  conversation,  or  of 
a  promenade,  or  of  musical  stances— to  which  he  was  passionately  devoted 
— served  to  banish  them  instantaneously  and  for  as  long  as  the  distraction 
endured.  Sleep  suspended  their  activity,  but  at  any  interruption  of  it 
they  scarcely  ever  failed  to  reassert  themselves. 

These  considerations  determined  my  view  of  his  trouble  as  a  peculiar 
form  of  tic,  which  consisted  in  "  muscular  spasms  systematically  harmonised 
to  produce  the  alternating  deglutition  and  expulsion  of  a  certain  quantity 
of  atmospheric  air"  (Pitres),  which  therefore  might  be  denominated  an 
aerophagic  tic. 

Different  varieties  of  this  tic  exist,  according  as  the 
air  swallowed  is  derived  from  the  exterior  or  from 
the  lung,  and  depending  on  its  penetration  into  the 
stomach  or  simply  into  the  pharyngo-cesophageal  canal ; 
and  further,  the  physiological  mechanism  of  the  con- 
dition varies  with  them. 

Let  us  suppose  that  the  swallowed  air  comes  from  the  lung.  In  this 
case,  a  certain  quantity  of  air  is  imprisoned  at  the  beginning  of  expiration 
in  the  pharyngo-oesophageal  cavity,  whose  orifices  are  firmly  closed  by 
simultaneous  contraction  of  the  muscles  of  the  palate,  glottis,  and  base 
of  the  tongue.  At  this  moment  a  brisk  contraction  of  the  constrictors  of 
the  pharynx  drives  the  accumulated  air  out  by  the  mouth,  setting  the 
membranes  surrounding  the  supero-anterior  opening  of  the  cavity  into 
vibration  in  so  doing,  whereby  the  air  escapes  as  a  more  or  less  noisy 
eructation. 

Should  the  mouth  not  open  at  this  juncture,  however,  the  air  is 
compressed  and  crowded  back  into  the  lower  part  of  the  oesophagus, 
whence  it  passes  through  the  easily  dilatable  cardiac  ring  into  the  stomach, 


THE  DIFFERENT   TICS  201 

to  be  expelled  again  by  the  mouth  in  the  same  noisy  way  once  it  has 
accumulated  in  sufficient  quantity. 

The  deglutition  of  external  air  is  preceded  by  an  aspiratory  thoracic 
effort ;  closure  of  the  glottis  forces  the  oesophagus  to  open  under  the  stress 
of  increased  negative  intrathoracic  pressure,  and  to  suck  air  down.  When 
aspiration  ceases,  this  air  is  either  driven  out  forthwith,  or  gathered  in 
the  stomach,  as  we  have  just  seen. 

One  may  sometimes  notice  that  the  act  of  suction  is  succeeded  by 
movements  of  swallowing,  in  which  case  the  probability  is  that  at  the 
moment  of  aspiration  the  closure  both  of  glottis  and  of  pharynx  prevents 
the  penetration  of  atmospheric  air  into  either  the  trachea  or  the  gullet, 
in  spite  of  the  differences  of  pressure,  and  that  these  movements  allow 
its  passage  through  the  oesophagus. 

Aerophagia  is  by  no  means,  therefore,  a  simple  in- 
voluntary movement,  but  a  combination  of  systematised 
muscular  actions.  In  fact,  it  is  a  tic,  and  as  such  has 
both  a  physical  and  a  psychical  side. 

From  the  material  point  of  view  (to  quote  Seglas  again),  the  predominant 
symptom  is  the  eructation,  and  the  object  in  determining  the  accessory 
symptoms  is  to  distinguish  it  from  gastric  eructations  properly  so  called, 
the  consequence  of  improper  fermentation.  In  our  case  the  appetite 
is  good,  and  the  digestion  normal — tympanites,  splashing,  and  abdominal 
pain  are  all  absent.  The  gases  evolved  are  inodorous,  and  their  analysis 
in  different  cases  (Ponsgen,  Hoppe-Seyler,  Pitres,  Sabrazes  and  Riviere) 
has  shown  that  so  far  from  containing  any  abnormal  constituent,  they 
have  almost  the  same  composition  as  atmospheric  air.  Application  of 
the  ear  to  the  vertebral  column  at  the  level  of  the  stomach  enables  one 
to  detect  a  noise  that  appears  to  correspond  to  the  passage  of  air  into 
that  viscus,  and  less  than  a  second  later  comes  the  eructation. 

Facts  of  another  kind  indicate  the  participation  of  a  psychical  element. 
The  activity  of  the  tic  increases  under  the  influence  of  the  emotions 
and  decreases  or  disappears  momentarily  at  the  bidding  of  the  will. 
Distraction,  concentration  of  the  attention  on  some  particular  thing, 
speaking,  reading  aloud,  are  also  calculated  to  suspend  its  manifestations. 
In  some  cases,  especially  where  there  is  an  association  with  hysteria, 
support  is  given  to  the  theory  of  its  psychical  origin  by  the  observation 
that  prolonged  opening  of  the  mouth,  and  the  administration  of  mica 
panis  pills  or  of  distilled  water  tinted  with  methylene  blue,  have  had  a 
definite  effect  in  controlling  the  spasm  (Pitres).  Moreover,  the  co-existence 
or  pre-existence  of  intellectual  troubles  or  mental  peculiarities  is  often 
incontrovertibly  proved  by  a  painstaking  psychological  examination. 

In  reality   this  aerophagic  tic  is  a  symptom-complex  encountered  in 


202          TICS  AND    THEIR    TREATMENT 

very  different  pathological  conditions.  No  doubt  its  frequency  is  greatest 
and  its  development  highest  in  hysteria,  but  we  are  in  error  if  we 
suppose  that  it  is  the  exclusive  appurtenance  of  that  disease  :  its  occurrence 
in  our  case  of  general  paralysis  is  evidence  to  the  contrary.  I  have  noted 
it  where  there  was  not  the  slightest  suspicion  of  hysterical  antecedents. 
Nevertheless  its  relation  to  pathological  mental  states  of  some  form  or 
another  is  invariable. 

It  is  often  found  in  cases  of  insanity  of  the  ob- 
sessional or  of  some  other  type. 

I  have  had  an  opportunity  (says  S6glas)  of  observing  an  instance  of 
aerophagia  in  a  woman  of  fifty-four  years,  who  for  the  last  fifteen  years  has 
been  suffering  from  hypochondriasis  in  a  delusional  form.  She  believes  she 
has  a  hole  in  her  head,  and  that  her  brain  is  gangrenous  ;  she  is  no  longer 
conscious  of  her  body,  nor  of  her  food  as  it  passes  through.  "It  is 
like  a  cupboard  empty  of  everything  but  air."  Grafted  on  this  delusion 
is  an  aerophagic  tic,  upon  which  the  patient  relies  in  support  of  her 
contentions.  So  little  is  she  able  to  withstand  its  ceaseless  repetition 
that  the  sequence  of  muscular  actions  continues  though  the  tongue  be 
held  outside  the  mouth  or  fixed  with  a  spoon. 

I  have  seen  the  same  phenomenon  in  another  woman,  forty-six  years 
of  age,  afflicted  with  fixed  and  systematised  delusions  of  persecution. 
She  imagined  that  she  was  being  pursued  by  sorcerers,  who  had  cast 
a  spell  on  her  and  were  about  to  poison  her,  torture  her,  break  her  on 
the  wheel,  etc.  In  addition  to  very  distinct  and  frequent  verbal  hallucina- 
tions and  disorders  of  general  sensibility,  she  exhibited  several  tics,  one 
of  which  consisted  in  spasmodically  closing  her  eyes,  brandishing  her 
right  arm,  and  uttering  a  string  of  incomprehensible  words  ;  the  other  was 
this  aerophagic  tic,  characterised  by  a  jumble  of  quick  swallowing  move- 
ments, pharyngeal  grunts,  and  long-drawn-out,  sonorous  eructations.  All 
this  performance  was  rehearsed  two  or  three  times  a  minute  as  a  sort  of 
convulsive  discharge,  which  she  alleged  the  sorcerers  forced  her  to  emit 
in  spite  of  herself,  exactly  as  they  coerced  her  into  uttering  a  jargon  she 
did  not  understand,  and  wagged  her  tongue  at  their  own  sweet  will. 

To  quote  Seglas  again  in  conclusion : 

The  air-swallowing  tic  is  merely  a  syndrome  common  to  various 
pathological  conditions  differing  widely  enough,  but  all  alike  in  being 
associated  with  some  degree  of  mental  impairment,  in  which  perhaps  may  be 
discovered  the  actual  cause  of  the  condition.  It  cannot  therefore  be  looked 
upon  as  a  simple  spasm,  based  anatomically  on  a  reflex  arc,  but  must  be 
regarded  as  a  reaction  whose  substratum  is  a  cortico-spinal  anastomosis — 
that  is  to  say,  it  is  a  tic. 


THE  DIFFERENT   TICS  203 

Tics  of  vomiting  may  be  produced  if  the  diaphragm 
be  affected.  Nogues  and  Sirol1  have  reported  the  case 
of  a  woman  with  a  pharyngo-laryngeal  derangement 
resembling  vomiting,  except  as  far  as  the  actual  ejection 
of  alimentary  matters  was  concerned.  She  used  to 
become  conscious  of  a  sensation  of  constriction,  and  to 
feel  the  tickling  of  a  foreign  body  in  the  gullet;  at 
this  point  the  slightest  pressure  on  the  neck  provoked  a 
convulsive  attack,  in  which  all  the  pantomime  of  vomit- 
ing was  gone  through  without  the  actual  emesis  taking 
place. 

It  is  possible,  as  Nogues  and  Sirol  think,  that  the 
trouble  may  have  originated  in  a  reflex  spasm,  and  that 
with  the  disappearance  of  the  primary  irritation  a  new 
psychical  factor  operated  to  effect  its  repetition  and 
prolongation. 

The  designation  of  all  these  functional  disorders  as 
tics  is  not  always  justifiable,  and  their  separation  from 
the  corresponding  normal  act  is  frequently  a  task  of 
delicate  diagnosis,  but  patient  search  for  the  exciting 
cause  and  study  of  the  concomitant  mental  anomalies 
will  supply  the  necessary  indications. 

TICS  OF  RESPIRATION— SNORING,  SNIFFING,  BLOWING, 
WHISTLING,  COUGHING,  SOBBING,  AND  HICCOUGHING 
TIC5 

Respiratory  tics  are  exceedingly  numerous.  They 
concern  the  diaphragm  and  the  muscles  of  inspiration 
or  expiration,  and  are  accompanied  by  synergic  move- 
ments of  the  muscles  of  the  nose,  lips,  tongue,  palate, 
pharynx,  as  well  as  by  laryngeal  noises  or  by  tics  of  the 
face  and  limbs.  They  embody  disturbances  of  various 
functional  acts,  and  may  be  subdivided  into  inspiratory 
and  expiratory  tics. 

1  NOGUES  AND  SIROL,  Arch.  med.  de  Toulouse,  June  x,  1898. 


204          TICS  AND    THEIR    TREATMENT 

It  is  only  as  regards  their  frequency  that  such  reflex 
mechanisms  as  yawning  and  sneezing  are  liable  to  be 
modified  by  the  intervention  of  the  will.  Saenger1 
records  the  case  of  a  woman  twenty-nine  years  old,  not 
affected  with  hysteria,  who  used  to  suffer  from  attacks  of 
yawning  and  of  stiffness  in  the  arms,  followed  by  rapid 
contractions  of  the  tongue  lasting  for  about  a  minute. 
He  describes  the  condition  as  one  of  "  idiopathic  spasm  " 
— probably  a  species  of  tic.  It  is  in  hysteria,  however, 
that  functional  variations  in  sneezing  and  yawning  are 
most  commonly  found,  and  the  latter,  moreover,  may 
constitute  the  aura  of  an  epileptic  fit.  Yawning  occurs 
in  a  most  intractable  form  in  meningeal  affections,  and 
in  cerebral  and  cerebellar  tumours. 

"  Rhincho-spasm,"  a  snoring  tic,  has  been  observed 
by  Oppenheim  in  a  case  of  neurofibromatosis.  In  certain 
tics  of  this  nature,  and  in  sniffing  tics,  the  onset  is 
sometimes  attributable  to  the  presence  of  adenoids. 

Among  various  expiratory  tics  may  be  enumerated 
the  habit  of  blowing  through  one's  nose  or  mouth. 
Schapiro  has  reported  a  case  of  expiratory  "spasm" 
due  to  contraction  of  the  buccinators.  Whistling  ought 
to  be  considered  a  stereotyped  act,  rather  than  a  tic,  as 
Letulle  maintains. 

Spasmodic  troubles  of  respiration,  defined  indiffer- 
ently as  "  spasmodic  dyspnoea,"  "  spasmodic  asthma," 
"  spasmodic  cough,"  "  asphyxial  spasm,"  "  nervous 
cough,"  etc.,  ought  not  to  be  classified  as  tics ;  in 
many  cases  they  are  genuine  spasms,  arising  from 
some  irritation  in  sensory  paths.  At  the  instant  of 
any  contact,  or  under  the  influence  of  a  sudden  noise 
or  a  bright  light,  a  patient  of  Edel's  used  to  become 
distressingly  dyspnoeic.  Evidently  the  condition  was 
one  of  spasm. 

Coughing  tics  also  are  of  remarkably  common 
1  SAENGER,  Monatsch.  f.  Pysch.  u.  Neur.  1900,  p.  77. 


THE  DIFFERENT   TICS  205 

occurrence.  Many  individuals  ceaselessly  interrupt 
the  thread  of  their  conversation  to  make  more  or  less 
audible  explosive  expirations,  for  which  there  is  neither 
reason  nor  necessity,  since  the  respiratory  paths  are 
free  from  all  irritation  or  obstruction.  These  useless 
little  coughs  do  not  always  deserve  the  appellation 
of  tics :  in  many  instances  they  are  mannerisms 
comparable  to  the  gestures  of  conversation  or  re- 
flection, although  in  some  people  their  insistence, 
abruptness,  and  irresistibility  might  justify  their  in- 
corporation in  the  other  category.  Their  co-existence 
with  tics  of  face  and  limbs  has  been  noted,  as  in  a  case 
published  by  Tissie1  of  an  eight-year-old  child,  with 
ocular  and  facial  tic  and  spasmodic  cough. 

Clonic  contraction  of  the  diaphragm  gives  rise  to 
conditions  imitated  or  caricatured  by  the  tics,  in 
particular  sobbing  and  hiccoughing.  It  must  not,  of 
course,  be  forgotten  that  these  are  apt  to  occur  in 
hysteria,  as  well  as  in  organic  disease  of  the  nervous 
system,  and  in  grave  infectious  states.  Careful  and 
searching  inquiry  must  therefore  precede  any  expression 
of  diagnosis. 

Tonic  diaphragmatic  contraction  is  of  very  much 
greater  rarity.  In  such  cases  abdominal  respiration 
comes  to  a  momentary  standstill,  whereas  thoracic 
respiration  is  accelerated.  The  patient  is  in  imminent 
danger  of  being  asphyxiated,  and  the  insertions  of 
the  diaphragm  sometimes  become  painful.  What  is 
known  as  acute  pulmonary  eructation  is  occasionally  the 
sequel  to  this  convulsive  affection.  Tonic  contraction 
of  the  diaphragm  is  nearly  always  of  an  hysterical 
nature,  and  is  doubtless  akin  to  the  aerophagic  type. 

1  TISSIE,  "Tic  oculaire,"  etc.,  Journ.  de  med.  de  Bordeaux,  July  9, 
1899. 


CHAPTER    X 

TICS   OF   SPEECH 

IN  movements   of   inspiration   or   of  expiration    the 
passage  of  air  through  a  more  or  less  contracted 
glottis   gives    rise    to    all    sorts    of    sounds,     some   of 
which,  under  certain  conditions,  must  be  included  in  the 
category  of  tics. 

The  most  elementary  of  these,  and  at  the  same  time  the  most  common 
(says  Guinon),  is  the  involuntary  exclamation.  In  the  midst  of  his  tics 
and  grimaces,  a  cry — ah  ! — escapes  the  patient's  lips  at  intervals,  a  shrill, 
sudden,  and  momentary  cry  which  interrupts  his  talk,  or  breaks  in  on 
a  period  of  silence,  and  which  he  repeats  only  once  or  perhaps  several 
times  in  succession.  The  thread  of  his  conversation,  nevertheless,  is  seldom 
if  ever  discontinuous,  and  his  audience  is  witness  of  its  rationality  and 
accuracy  of  expression.  Rather  more  complicated  is  the  ejaculation 
"  ouah  !"  Sometimes  one  meets  with  noises  that  are  faithful  reproduc- 
tions of  the  sounds  emitted  by  various  animals. 

Guinon  is  disposed  to  exclude  such  simple  involuntary 
explosions  as  "  ahem !  ahem !  "  from  the  tics,  though  he> 
admits  the  analogy  to  them.  He  says  the  sound  exactly 
resembles  the  trifling  little  clearance  of  the  throat  which 
is  repeated  a  thousand  times  a  day  by  people  suffering 
from  chronic  angina.  We,  however,  are  inclined  to  look 
upon  it  as  an  ordinary  spasmodic  reaction  evoked  by 
some  laryngeal  or  pharyngeal  irritation,  which  in  spita 
of  the  removal  of  the  latter  continues  to  take  place,  and 
because  of  its  meaningless  repetition  is  fairly  to  be 
classed  as  a  tic.  All  that  we  have  said  of  blinking,, 
for  instance,  is  applicable  in  this  connection. 

Of  course  the  embellishment  of  one's  discourse  with. 

206 


TICS   OF  SPEECH  207 

more  or  less  audible  expirations  is  of  frequent  occurrence  i 
the  hesitating  eh  ...  eh  ...  to  which  children  give 
vent  in  the  recitation  of  their  lessons  is  not  confined 
to  them  alone.  It  can  scarcely  be  maintained  that 
these  laryngeal  noises  are  tics,  since  their  production 
is  coincident  with  the  exercise  of  the  faculty  of  speech  \ 
hence  they  are  not  unlike  "  functional  cramps."  On 
the  other  hand,  the  unexpected  bark  or  gurgle  that 
breaks  the  silence  is  a  pure  tic  of  phonation.1  Those 
who  suffer  in  this  way  reveal  characteristic  stigmata 
in  the  immediateness  of  the  compelling  idea  and  the 
exaggerated  nature  of  the  subsequent  satisfaction.  To 
unravel  the  intricacies  of  the  origin  of  these  tics  is 
a  matter  of  considerable  difficulty,  though  probably 
imitation  is  not  without  influence  in  their  genesis. 
Reference  will  be  made  later  to  a  tic  of  this  kind 
attributed  by  Charcot  to  imitation. 

Among  the  insane  similar  cries  are  often  the  out- 
come of  delusions.  At  the  Congress  of  Limoges  a. 
case  was  reported  by  Briand  of  an  old  man  who 
imagined  himself  transformed  into  a  clock  and  swung 
his  arms  with  pendulum-like  regularity,  indicating  the. 
hours  by  uttering  raucous  sounds  at  the  proper  intervals. 
However  curious  these  sounds  were,  the  fact  of  their 
being  appropriate  is  decisive  against  their  classification 
as  tics. 

Unmistakable  tics  of  speech,  however,  do  occur. 

Speech  is  a  complex  of  different  muscular  acts, 
and,  being  so,  is  liable  to  be  disarranged  in  various, 
ways,  by  defect  in  respiration,  phonation,  articulation, 
even  in  ideation.  Organic  affections  aside,  it  is  in- 
admissible  to  describe  as  tics  each  and  all  of  the 
functional  disturbances  of  speech  that  are  not  based 
on  any  discoverable  material  lesion  of  nerve  centres. 
One  must  in  fact  distinguish  between  troubles  of  speech 
1  CHARCOT,  Lemons  du  mardi,  January  24,  1888. 


208          TICS  AND    THEIR   TREATMENT 

confined  to  occasions  when  the  faculty  is  in  operation 
and  those  that  consist  in  not  merely  useless  but  in- 
opportune utterance.  However  arduous  it  may  occa- 
sionally be  to  draw  this  distinction,  however  common 
the  occurrence  of  transitional  forms,  it  has  the  advantage 
of  limiting  the  scope  of  the  term  "  tic  of  language." 
To  the  latter  category  only  can  the  description  be 
applied. 

For  this  reason  we  think  it  preferable  to  exclude 
stammering,  stuttering,  and  all  defects  of  phonation  or 
articulation  whose  existence  is  revealed  only  in  the  act 
of  speaking.  At  the  same  time  reference  must  be  made 
to  facts  linking  these  functional  anomalies  to  the  tics, 
and  to  instances  of  the  latter  existing  with  or  succeeding 
the  former. 

Such  is  the  case  with  stammering. 

According  to  Letulle,1  stammering  is  a  tic  of  speech 
whose  beginning  is  a  functional  disturbance  of  nervous 
centres,  as  is  that  of  tics  in  general.  Holding  as  we  do, 
however,  that  one  of  the  features  of  tic  is  its  appearance 
in  season  and  out  of  season,  we  cannot  class  stammering 
as  a  tic,  since  its  exhibition  is  restricted  to  the  exercise 
of  a  certain  function,  viz.  speech.  It  is  therefore 
comparable  to  a  "professional  cramp,"  and  we  may 
briefly  note  the  analogies  it  offers  to  the  tics. 

Stammering,2  which  in  more  than  fifty  per  cent, 
of  cases  is  hereditary,  and  associated  with  a  neuropathic 
diathesis,  usually  betrays  itself  in  childhood  and  becomes 
aggravated  at  puberty.  The  old  idea  which  credited 
stammerers  with  exceptional  intellectual  powers,  in 
whom,  however,  rapidity  of  thought  surpassed  rapidity 
of  action  on  the  part  of  the  muscles  of  articulation, 

1  LETULLE,  "  Un  cas  de  b6gaiement  compliqug  de  tics  coordine's 
multiples,"  Gazette  med.  de  Paris,  1883,  p.  536. 

1  OLIVIER,  "  Le  begaiement  dans  la  literature  mddicale,"  La  parole, 
No.  10,  1899. 


TICS   OF  SPEECH  209 

is  exploded,  and  to-day  those  thus  afflicted  are  as- 
signed their  true  place  among  the  volitionally  infirm. 
In  a  few  rare  cases  stammering  has  been  due  to 
organic  disease  of  the  centres  for  articulate  speech, 
or  of  bulbo-pontine  nuclei ;  it  has  been  supposed  also 
to  result  from  genuine  spasm  on  a  reflex  arc,  and  this 
is  a  possible  explanation ;  as  a  general  rule,  however, 
the  pathogeny  of  stammering  is  identical  with  that  of 
tic.  Its  dependence  on  such  affections  of  nose,  larynx, 
and  pharynx  as  hypertrophic  rhinitis  and  adenoids 
has  been  emphasised  by  Biaggi l ;  and  Derevoge,8 
in  directing  attention  to  the  association  of  volitional 
enfeeblement  with  respiratory  troubles,  remarks  that 
stammerers  sometimes  have  a  phobia  for  certain 
words.  Many  observers  have  been  convinced  of  the 
psychical  nature  of  the  affection  from  the  fact  of 
its  disappearance  during  singing,  as  well  as  from 
the  effect  anger,  elation,  and  other  stimuli  have  in 
momentarily  inhibiting  it.  The  same  is  of  course  true 
of  the  tics. 

Further,  little  attempt  is  made  either  by  the 
tiqueur  or  the  stammerer  to  correct  his  failing,  so 
that  prognosis  improves  with  the  adoption  of  system- 
atic treatment.  Stammering  is  a  functional  anomaly; 
it  is  a  derangement  of  respiration,  phonation,  and 
articulation.  However  normal  be  the  movements  of 
lips  and  throat  in  the  execution  of  certain  acts,  they  are 
far  from  being  normal  in  the  exercise  of  speech.  As  a 
preliminary  to  speaking  the  stammerer  clenches  his  teeth 
and  approximates  his  lips,  thus  effectually  preventing 
the  inrush  of  air  except  by  the  nares ;  simultaneously 
he  contracts  his  tongue  and  obstructs  the  isthmus  of  the 
pharynx,  while  the  glottis  also  may  close  spasmodically. 
Then  he  abruptly  expands  his  thorax  and  inhales  a 

1  BIAGGI,  Arch.  iial.  di  otologia,  1897. 
1  DEREVOGE,  These  de  Bordeaux,  1898. 

14 


210         TICS  AND    THEIR    TREATMENT 

considerable  quantity  of  air,  yet  is  he  ever  on  the  verge 
of  breathlessness,  for  he  cannot  voluntarily  arrest 
himself,  or  make  a  break  between  two  respirations. 
He  seeks  to  continue  speaking  though  his  lungs  are 
empty  of  air ;  he  cannot  control  expiration  by  antagon- 
istic contraction  of  inspiratory  muscles ;  often  he  finds 
himself  unable  to  commence  speaking  at  all. 

The  glottis  is  either  open,  allowing  the  silent  escape 
of  air,  or  it  is  completely  occluded.  In  the  midst 
of  syllables  or  words  the  voice  is  frequently  "  cut " 
by  a  sudden  halt  indicative  of  spasmodic  closure 
of  the  glottis.  A  contrast  to  the  ease  with  which 
vowels  are  pronounced  is  provided  by  the  difficulty 
experienced  in  the  enunciation  of  various  consonants. 
Convulsive  movements  of  the  lips  frustrate  the  en- 
deavour to  form  the  series  of  successive  positions  which 
the  consonants  demand. 

An  association  of  stammering  with  convulsive 
phenomena  of  a  different  nature  has  often  been  re- 
marked. Instances  of  this  have  been  given  by  Janke.1 
One  patient  takes  a  few  paces  backward,  limping  with 
his  left  leg  till  he  finds  something  to  give  him  support, 
and  knocking  his  shoulder  several  times  against  wall- 
or  furniture,  as  soon  as  he  encounters  it ;  if  he  is 
seated  he  rises  slowly  from  the  chair,  holding  it  with 
his  hands  the  while,  and  forthwith  falls  back  into  his 
seat  in  order  to  begin.  Another  taps  his  fingers  on 
his  thigh  whenever  the  word  he  is  about  to  utter' 
commences  with  "  g  "  or  "  k." 

In  Brissaud's  clinique  we  have  met  with  a  couple 
of  instructive  cases: 

The  first  concerned  a  showman  who  used  to  exhibit  a  series  of 
dissolving  objects  by  means  of  mirrors,  and  who  found  one  day  that 
he  could  not  speak  without  scanning  his  syllables  and  explosively 
ejaculating  his  words  ;  at  the  same  time  his  conversation  was  punctuated 

1  JANKE,  III*  Congres  des  medecins  tchiques  a  Prague,  1901. 


TICS  OF  SPEECH  211 

by  sudden  and  exaggerated  shutting  of  the  eyes  and  by  facial  contortions. 
After  a  pause  the  inauguration  of  a  phrase  was  ushered  by  still  more 
energetic  and  widespread  spasms  of  the  head  and  even  of  all  the  body. 

The  other  was  an  eighteen-year-old  Jewish  boy,  who  before  beginning 
to  speak  gave  vent  to  a  hard  sound  like  "kh"  four  or  five  times 
in  succession,  each  being  accompanied  by  a  violent  rotation  of  the 
head  to  the  right,  wrinkling  of  the  face,  and  a  little  jump.  The  patient 
then  addressed  himself  to  speak  with  the  utmost  assurance,  there  being 
no  sign  of  tic  or  stammer  unless  he  stopped  for  a  moment  and 
endeavoured  to  recommence.  On  the  other  hand,  he  could  sing  to 
perfection. 

There  may  also  be  troubles  of  speech  of  a  tonic 
kind,  whereby  a  more  or  less  complete  and  sustained 
mutism  is  produced,  an  excellent  example  of  which 
has  recently  come  under  our  notice : 

A  young  girl,  various  members  of  whose  family  are  stammerers, 
occasionally  suffers  from  an  extraordinary  sensation  of  anguish  in  the 
course  of  conversation  ;  she  flushes  and  then  becomes  suddenly  immobile, 
finding  it  impossible  to  articulate  or  even  to  utter  a  sound.  Her  glottis 
contracts  forcibly ;  her  efforts  at  expiration  are  ineffectual,  or  else  the  air 
escapes  in  little  explosive  puffs,  and  at  the  same  time  her  lips  twitch 
and  her  eyelids  flicker.  The  whole  seizure  is  over  in  a  few  seconds, 
whereupon  the  patient  launches  into  conversation  with  volubility,  until 
pulled  up  by  a  fresh  attack.  She  shows  remarkable  acumen,  moreover, 
in  an  analysis  of  her  symptoms.  "  What  happens  is  that  I  am  suddenly 
overwhelmed  with  the  fear  of  being  unable  to  pronounce  a  given  word, 
and  at  the  thought  my  lips  are  sealed,  I  cannot  make  a  sound,  my  throat 
is  compressed,  my  tongue  refuses  to  obey  me,  and  my  condition  becomes 
one  of  abject  misery."  Curiously  enough  her  phobia  is  not  related  to  a 
particular  word,  and  moreover  her  articulation  is  accurate  and  not 
embarrassed  in  presence  of  certain  of  the  consonants.  Phonation  and 
respiration  are  implicated  as  well  as  articulation.  The  origin  of  this 
"  cramp  of  speech  "  in  psychical  abnormalities  is  manifest. 

To  a  similar  affection  characterised  by  total 
inability  to  speak  in  a  high  or  a  low  voice,  whispering 
only  being  practicable,  the  term  "  spastic  aphonia " 
has  been  applied.  It  is  at  the  moment  when  the  patient 
wishes  to  speak  that  the  spasm  occurs,  as  in  a  case 
reported  by  Hasslauer,1  which  resisted  all  treatment 

1  HASSLAUER,  "  Ueber  spastischen  Stimmritzen  Krampf,"  Mili- 
taraertz  Zeitschrift,  1900,  p.  417. 


212          TICS  AND    THEIR    TREATMENT 

and  was  considered  by  him  to  have  features  in  common 
with  hysteria  and  occupation  neuroses. 

There  can  be  little  doubt  that  the  arrest  of  move- 
ment in  these  cases  is  comparable  to  what  obtains  in 
writers'  cramp,  and  therefore,  rigorously  speaking,  a 
tonic  tic. 

A  case  has  been  recorded  by  F.  Pick l  of  a  man 
of  thirty-eight  years  of  age  afflicted  with  convulsive 
movements  of  the  face  and  troubles  of  speech. 

Whenever  the  patient  tried  to  speak  oral  contortions  and  deviation 
of  the  tongue  ensued,  and  hands  and  feet  began  to  beat  the  air  without 
his  being  able  to  utter  a  single  word.  The  agitation  was  increased  by 
emotion  and  diminished  with  volitional  movement. 

Another  instance  is  referred  to  by  Aime"2  under  the 
name  of  tic  of  elocution,  where  the  combination  of 
convulsive  movements  of  neck,  shoulder,  and  arm  with 
spasm  of  articulation  of  eight  years'  standing  dis- 
appeared under  the  influence  of  methodical  re-education. 

Kopczynski  cites  the  case  of  a  man  with  facial  and 
other  tics  who  used  often  to  utter  a  long  string  of 
words  or  even  a  whole  sentence  in  an  extremely 
monotonous  voice,  resuming  his  natural  tone  thereafter  ; 
occasionally,  too,  he  used  to  pause  in  the  middle  of  a 
remark  for  as  long  as  forty  seconds. 

Mention  must  be  made  here  of  true  spasms  of 
phonation  or  laryngospasms,  the  result  of  local  irritation, 
which  disappear  with  its  removal.  Central  lesions,  of 
course,  might  conceivably  produce  the  same  effect. 

Uchermann8  has  reported  a  case  of  recurrent  attacks  of  mutism  at 
intervals  of  five  or  ten  minutes  in  a  man  of  sixty-eight,  examination  of 
whose  larynx  during  the  seizure  showed  the  glottis  to  be  in  spasm. 
Synchronously  with  these  rhythmical  clonic  alternations  of  adduction  and 

1  PICK,  Socitte  des  mtdecins  allemands  a  Prague,  March  10, 1893. 
1  AIME,    "  Un   cas   de    tic  elocutoire,"   Revue  medicale    de    test, 
January  I,  1901. 

3  UCHERMANN,  Arch.  f.  Loryngologie,  1898,  p.  326. 


TICS  OF  SPEECH  213 

abduction  occurred  tonic  contractions  of  the  masseters  and  clonic  con- 
tractions of  the  palate,  tongue,  and  forearm.  The  phenomena  had  lasted 
for  about  a  month  when  a  right  hemiplegia  was  superadded,  and  was 
followed  by  a  fatal  issue  three  weeks  later.  Unfortunately  no  autopsy 
was  obtained  to  verify  the  observer's  opinion  of  a  lesion  in  the  neighbour- 
hood of  the  left  precentral  sulcus,  involving  the  centres  for  mastication 
and  phonation,  for  the  tongue  and  for  opening  of  the  glottis. 

If  now  we  direct  our  attention  to  the  content  of 
speech,  we  shall  see  how  it  too  may  reveal  anomalies 
not  unlike  tics. 

Letulle  quotes  the  case  of  a  man  who  could  not 
utter  four  consecutive  words  without  sandwiching  a 
"  sir  "  between  them.  Similarly,  the  "  don't  you  know," 
"do  you  see,"  "you  know,"  of  so  many  people 
are  repeated  ad  infinitum.  One  of  us  has  an  acquaint- 
ance who  interlards  his  talk  with  "  you  understand," 
and  this  formula  is  reiterated  without  modification 
though  he  may  be  addressing  his  friend  in  the  second 
person  singular. 

There  used  to  be  a  poor  creature  driven  by  destitu- 
tion to  sell  papers  in  the  streets,  or  to  figure  as  a  negro 
in  the  corridors  of  the  Hippodrome,  who  was  wont  to 
garnish  his  speech  with  a  "  Well,  my  boy !  all  right, 
by  Jove ! "  repeated  at  intervals,  whoever  it  was  he 
happened  to  be  speaking  to,  and  even  though  it  was 
their  first  time  of  meeting. 

In  Ibsen's  play  of  Hedda  Gabler  is  a  character  George 
Tesman,  a  weak  being  who  begins  every  sentence  with 
"  I  say,  Hedda,"  and  ends  with  a  no  less  invariable 
"  eh  ! " l 

These  habitual  words  and  phrases — and  many 
more  instances  may  be  cited — are  analogous  to  the 
mannerisms  exhibited  during  concentration  of  the  atten- 
tion on  the  performance  of  certain  acts.  They  cannot  be 
considered  tics  unless  reproduced  at  other  times  as  well. 

1  GEYER,  "  Etude  m6dico-psychologique  sur  le  theatre  d'Ibsen," 
These  de  Paris,  1902. 


214         TICS  AND    THEIR    TREATMENT 

Moreover,  while  the  use  of  such  terms  may  be  overdone, 
it  can  hardly  be  said  to  be  unreasonable.  However 
irritating  their  effect,  they  indicate  simply  an  exuberance 
of  style  and  a  degree  of  inattention,  not  a  grave  mental 
shortcoming. 

Of  a  less  trivial  nature  is  a  curious  anomaly  that 
consists  in  the  complication  of  speech  by  the  intro- 
duction of  meaningless  expressions  uncontrolled  by  the 
will.  This  is  a  functional  defect  very  much  akin  to 
the  tics. 

A  distinguished  medical  colleague  was  in  the  habit 
of  muttering  the  word  cousisi  as  he  talked.1  Seglas 
described  similar  occurrences  as  "  stereotyped  acts  of 
speech."  One  of  the  Salpetriere  patients  used  to  close 
every  sentence  with  the  phrase  "  in  all  and  for  all." 
Another's  opening  remark  was  always  "  Araken-Doken- 
Zoken."  It  is  permissible  to  regard  many  of  the 
neologisms  imagined  by  the  insane  as  examples  of 
stereotyped  speech.  A  patient,  for  instance,  who  suffered 
from  delusions  of  persecution,  said  he  was  being  pursued 
by  the  Evil  Eye  ("  reluquets " — reluquer,  to  leer  at). 
With  the  eventual  disappearance  of  the  association 
linking  the  original  idea  to  the  neologism,  the  patient 
may  no  longer  be  capable  of  explaining  the  meaning 
of  the  phraseology  he  has  invented,  but  in  the  case 
of  those  whose  mental  level  is  more  nearly  normal 
the  coining  of  new  words  need  not  be  more  than  a 
sort  of  eccentricity,  which  is  generally  accompanied, 
however,  by  other  indications  of  instability.  We  may 
remind  ourselves  of  0.,  with  his  "  vertigos "  and 
"  para-tics." 

But  if,  finally,  words  or  phrases  escape  the  subject's 

lips  at  moments  of  silence,  with  whose  imperious  and 

unexpected  emission  he  is  powerless  to  cope,  then  we 

are    dealing    with    true    tics    of    speech.      Their    in- 

1  GRASSET,  Clinique  mtdicaU,  1891. 


TICS   OF  SPEECH  215 

vestigation  lias  been  conducted  by  Guinon  with  great 
analytical  skill. 

At  the  upper  end  of  the  ladder  among  exclamations  we  meet  words 
involuntarily  and  senselessly  repeated,  in  a  loud  tone  of  voice,  to  the 
accompaniment  of  tics  and  grimaces.  These  expressions  fall  naturally 
into  two  groups  that  require  to  be  rigorously  differentiated. 

In  the  first  of  these  the  words  uttered  may  be  simply  anything  ; 
each  patient  may  have  his  own,  and  so  their  number  is  absolutely 
limitless.  Occasionally  one  is  in  a  position  to  discover  in  the  antecedents 
of  the  case  the  reason  for  the  choice  of  a  particular  word  in  preference 
to  another,  as  in  the  instance  of  the  man  whose  involuntary  ejaculation, 
"  Maria  ! "  was  the  echo  of  a  passion  he  had  conceived  years  before  for 
a  young  girl  of  that  name. 

Such  troubles  are  unmistakable  tics.  The  mechanism 
of  their  production  is  identical,  be  the  actual  localisation 
brachial,  facial,  or  laryngeal,  and  this  applies  in  par- 
ticular to  the  motor  verbal  hallucinations  so  excellently 
studied  by  Seglas.  As  a  matter  of  fact,  tics  of  speech 
are  often  nothing  more  than  the  mode  of  exteriorisation 
of  these  hallucinations.  The  same  is  the  case  with 
verbal  impulsions. 

In  this  rubric  of  tics  of  speech  we  may  class  various 
cases  recorded  under  differing  titles,  among  which  an 
interesting  one  due  to  Pitres  may  be  quoted : 

Subsequently  to  his  retirement  from  active  business  pursuits,  the  patient, 
a  man  fifty-nine  years  old,  became  depressed,  morose,  and  irritable,  till 
insomnia  at  length  drove  him  in  desperation  to  attempt  suicide.  By  the 
merest  chance  he  failed  of  his  purpose.  The  development  of  involuntary 
sounds  a  few  weeks  later  was  followed  at  the  end  of  a  month  by  the 
equally  involuntary  ejaculation  of  his  wife's  and  children's  names — "  Numa  ! 
Helen  !  Camille  !  Maria  !  "  This  habit  persisted  for  as  long  as  fourteen 
months,  after  which  during  three  years  he  enjoyed  excellent  health. 
Owing  to  financial  worries,  however,  a  relapse  occurred.  Every  few 
minutes  he  uttered  various  articulate  cries  in  a  loud,  clear,  and  well- 
modulated  voice,  sometimes  repeating  the  four  names  with  great  rapidity, 
at  others  calling  out  the  same  name  with  increasing  violence.  Severe 
convulsive  twitches  of  arm  and  trunk  musculature  synchronised  with  his 
exclamations.  The  patient  was  incapable  of  either  restraining  or  even 


216         TICS  AND    THEIR    TREATMENT 

modifying  the  cries  ;  he  was  equally  unable  to  replace  one  by  another, 
to  say  Henry  instead  of  Numa,  or  Jean  instead  of  Helen. 

For  hours  at  a  stretch  he  would  repeat  the  names  of  friends  who  had 
come  to  visit  him  ;  on  the  day  before  a  consultation  on  his  case  his 
one  cry  was  the  name  of  the  new  physician  who  was  going  to  examine 
him. 

A  gradual  improvement  took  place,  and  eighteen  months  after  the 
onset  of  the  condition  the  cure  was  complete. 

In  the  same  connection  Pitres  refers  to  a  case 
reported  by  Calvert  Holland. 

A  miner  who  had  gone  through  the  experience  of  incipient 
suffocation  found  himself  two  months  later  irresistibly  impelled  to  ex- 
uberant speech.  The  rapidity  and  indistinctness  of  his  enunciation  of 
words  were  very  much  in  evidence,  as  well  as  a  tendency  to  stammering 
and  to  tautology.  A  further  symptom  consisted  in  rotatory  spasms  of 
the  head  ;  but  after  five  months  a  satisfactory  cure  resulted. 

"We  may  cite  a  last  instance  from  Ball : 

A  young  girl  was  in  the  habit  of  kneeling  down,  making  the  sign  of 
the  cross,  and  repeating  "Jesus,  Mary,  Joseph."  The  performance  was 
limited  to  this  order  of  events,  but  its  practice  in  drawing-rooms  and  still 
more  in  thoroughfares  led  to  her  being  certified  as  insane. 


ECHOLALIA 

In  his  description  of  the  disease  which  bears  his 
name,  Gilles  de  la  Tourette  used  the  expression  echolalia 
to  denote  a  certain  phenomenon  of  occasional  occurrence 
among  those  who  tic. 

The  patient  (says  Guinon)  repeats  echo-like  the  sounds  he  hears 
around  him,  and  like  the  echo  his  reproduction  of  them  is  more  or 
less  lengthy.  In  its  mildest  form  the  symptom  may  consist  in  the 
repetition  of  a  simple  involuntary  "ah  !"  which  some  one  near  by  has 
ejaculated,  or  the  last  word  or  two  of  some  one's  talk  is  mimicked,  or 
in  a  more  advanced  stage  the  whole  of  a  phrase  is  reproduced. 

As  a  general  rule  the  "  echo  "  is  rather  obtrusive,  but  its  commence- 
ment at  least  may  be  very  different,  the  patient  being  astonished  to 
find  himself  repeating  in  a  subdued  tone  of  voice  what  he  hears  others 
saying  ;  and,  struggling  in  fear  to  rid  himself  of  the  habit,  he  ends  by 
sinking  into  a  state  of  actual  anguish.  It  is  at  this  moment  that  he  fails 


TICS   OF  SPEECH  217 

to  inhibit  his  impulses  and  gives  vent  to  the  word  he  has  been  endeavouring 
to  check,  which  he  may  repeat  loudly  and  violently  in  a  sort  of  fury. 
The  fidelity  and  clearness  with  which  the  utterances  of  others  are 
imitated  are  remarkable. 

Sometimes  by  an  effort  of  the  will  the  patient  is  able  to  suppress,  it 
may  be  imperfectly,  the  impulse  to  echo,  so  that  while  his  tongue 
is  under  his  control,  his  will  gives  rein  to  his  other  tics,  and  a  regular 
muscular  debauch  takes  place.  In  the  mildest  cases  he  can  replace 
a  word  by  a  movement,  by  a  little  cough  or  an  insignificant  "  ahem  !  " 
but  not  beyond  a  certain  point,  for  he  will  thus  restrain  himself  only 
when  he  is  forewarned  ;  a  sudden  and  unexpected  ejaculation  in  his 
neighbourhood  will  catch  him  off  his  guard. 

In  spite  of  their  frequency  among  those  who  are 
addicted  to  tic,  echolalia  and  echokinesis  cannot  be 
enumerated  with  the  tics,  seeing  that  their  exhibition  is 
dependent  on  the  actions  of  others,  whereas  once  a  tic 
is  established  it  requires  no  stimulus  from  without  for 
its  manifestation.  Of  course  their  affinity  to  the  tics 
is  very  close  :  they  spring  from  the  same  soil ;  they 
represent  in  the  adult  the  persistence  and  amplification 
of  the  child's  propensity  for  imitation,  and  therefore 
in  their  own  way  postulate  a  degree  of  mental  in- 
fantilism. 

Echolalia  in  the  blind  has  been  made  the  subject 
of  an  interesting  study  by  Noir. 

The  echolalic  repeats  abruptly  and  rapidly  what  is  said  by  others 
in  his  presence.  That  he  does  not  stop  to  reflect  is  attested  by  his 
mimicry  of  bizarre  words,  technical  terms,  even  of  idioms  in  a  foreign 
language. 

It  is  an  interesting  fact  that  of  twelve  cases  of  echolalia  that  have 
come  under  our  observation,  fifty  per  cent,  occurred  among  the  blind. 
The  coincidence  is  a  rational  one  ;  blindness  and  echolalia  are  united  as 
cause  and  effect.  In  the  case  of  the  person  born  blind  the  auditory  memory 
is  in  such  an  advanced  state  of  development  that,  if  he  be  not  very 
intelligent,  he  will  seek  to  fix  the  sound  of  an  auditory  impression  in 
his  defectively  organised  mind  as  soon  as  he  hears  it,  and  being  unable 
to  whisper  it  mentally,  he  stimulates  his  auditory  centres  by  a  less  delicate 
process,  and  forthwith  repeats  aloud  the  word  he  has  just  heard.  This 
is  why  we  meet  with  instances  of  the  echolalic  blind  repeating  a  sentence 


218          TJCS  AND    THEIR   TREATMENT 

before  replying  to  it.  It  is  instructive  to  note  in  this  connection  that 
the  choicest  example  of  echokinesis  we  have  seen  was  in  a  deaf  mute, 
in  whom  no  doubt  the  visual  phenomena  were  analogous  to  the  auditory 
phenomena  of  the  echolalic. 

Noir  is  inclined  to  apply  this  mechanism  to  the  case 
of  echolalics  who  are  not  actually  blind.  He  quotes 
instances  which  go  to  show  that  their  visual  memory  is 
awanting,  that  as  far  as  it  is  concerned  they  are  "  blind." 

The  hypothesis  is  attractive.  It  may  be  further 
remarked  that  the  echolalic  is  a  "  motor,"  in  the  same 
way  as  the  patient  afflicted  with  hallucinations  of  sight 
or  hearing  is  an  "  auditory  "  or  a  "  visual." 

Echolalia  is  amenable  to  treatment,  and  is  even 
capable  of  cure.  Noir  gives  an  interesting  example 
of  the  evolution  of  the  process. 

If  I  say  to  an  echolalic,  "  Are  you  hungry  ? "  he  will  instantly 
answer,  "  Are  you  hungry  ? "  Under  the  influence  of  re-education  the 
reply  will  eventually  change  to  "Are  you  hungry  ?  are  you.  .  .  .  ? 
Yes,  sir,  I'm  hungry,"  then  to  "  Yes,  sir,  I'm  hungry,"  and  finally 
to  "Yes,  sir." 

Echolalia,  however,  is  not  an  exclusive  appurtenance 
of  those  who  tic.  We  can  remember  a  case  of  general 
paralysis  in  the  clinique  of  Brissaud  at  the  Hotel  Dieu, 
who  had  the  regular  habit  of  repeating  the  question 
that  was  addressed  to  him  ;  if  it  were  a  little  long, 
only  the  last  ten  or  fifteen  words  were  echoed.  A 
case  is  quoted  by  Cantilena  of  a  woman  with  right 
hemiplegia  and  partial  epilepsy  who  invariably  re- 
iterated the  closing  phrase  of  anything  said  to  her. 
Several  cerebral  tumours  were  discovered  at  the  autopsy. 

It  is  conceivable  of  course  that  an  actual  lesion, 
as  well  as  a  congenital  developmental  defect,  may 
interfere  with  the  will's  inhibitory  powers,  in  which 
case  auditory  or  visual  stimuli  are  transmitted  to  motor 
centres  unmodified,  the  result  being  the  production  of 
sounds  or  of  other  movements. 


TICS   OF  SPEECH  219 


COPROLALIA 

Coprolalia,  the  manie  blasphematoire  of  Verga,  is, 
according  to  Grilles  de  la  Tourette,  one  of  the  most 
frequent  affections  of  speech,  in  the  disease  of  con- 
vulsive tics. 

There  is  no  necessary  connection,  as  a  matter  of 
fact,  between  tic  and  coprolalia,  though  of  course  they 
may  co-exist,  sometimes  in  association  with  other 
syndromes ;  they  are  in  reality  only  episodic  syndromes 
of  hereditary  insanity. 

A  distinction  ought  to  be  drawn  between  coprolalia 
and  the  use  of  trivial  or  inconvenient  terms,  words 
with  which  even  some  well-educated  persons  are  wont 
to  garnish  their  conversation.  Guinon  had  a  case  of 
a  man  who  in  the  presence  of  his  mother  resorted 
to  language  of  a  kind  absolutely  disallowed  in  polite 
society.  In  the  etymological  sense  of  the  word,  no 
doubt,  he  was  a  coprolalic,  but  it  cannot  be  said  that 
he  was  suffering  from  tic. 

On  the  other  hand,  the  abrupt  and  impetuous 
utterance  of  oaths  or  obscene  expressions,  to  the  ejacula- 
tion of  which  an  irresistible  impulse  seems  to  drive  the 
patient  independently  of  time  and  place,  amounts  to 
a  coprolalic  tic  of  speech,  and  reveals  a  deplorable 
volitional  debility  on  his  part ;  for  he  is  incapable  of 
checking  an  act  to  the  impropriety  of  which  he  is 
fully  alive. 

The  victims  of  this  disease  (says  Guinon)  have  an  extraordinary 
propensity  for  choosing  the  foulest  and  most  indecent  words,  however 
elevated  their  position  and  correct  their  breeding.  Reference  may  be 
made  to  the  classic  instance  of  the  Marquise  de  Dampierre,  who  all 
her  long  life  was  in  the  habit  of  repeating  certain  immodest  sayings  even 
on  the  most  solemn  occasions. 

According  to  Guinon  the  reason  of  this  bizarre 
preference  for  obscene  remarks  is  absolutely  unknown, 


220         TICS  AND   THEIR  TREATMENT 

although  Charcot's  view l  that  coprolalia  is  frequently 
nothing  more  than  echolalia  is  one  of  some  plausibility. 
He  refers  to  one  of  his  patients  who  alternated  her 
coprolalic  utterances  with  a  sort  of  barking  noise  that 
was  an  exact  imitation  of  her  favourite  dog. 

We  ourselves  have  had  for  a  long  time  under 
observation  a  youth  in  the  service  of  Professor  Brissaud 
whom  some  instinct  seemed  to  prompt  to  repeat  any 
lewd  expression  he  happened  to  hear,  or  indeed  any 
which  might  be  so  interpreted.  It  might  then  be  said 
of  him  that  his  coprolalia  varied  with  his  surroundings 
and  with  his  own  ideas ;  it  was  accompanied  by 
inconstant  and  irregular  convulsive  movements  of  the 
limbs. 

After  all,  there  is  not  so  very  much  to  choose  between 
the  coprolalic  and  the  individual  whom  impatience  or 
anger  forces  to  blaspheme  or  at  any  rate  to  utter 
words  that  do  not  form  part  of  his  ordinary  vocabulary. 
And  though  the  ejaculation  be  not  audible,  the  first 
degree  of  coprolalia  consists  in  the  mental  presentation 
of  the  objectionable  phrase.  Among  those  who  suffer 
from  obsessions  mental  coprolalia  is  far  from  uncommon. 
A  patient  with  folie  du  doute,  mentioned  by  Seglas,2  was 
afraid  to  pronounce  indelicate  words  because  he  felt 
himself  articulating  them  mentally,  and  sometimes  he 
used  to  ask  whether  they  had  not  really  escaped  him. 
One  step  more,  and  these  verbal  hallucinations  assume 
the  characters  of  a  genuine  tic. 

1  CHARCOT,  Lefons  du  mardi,  October  23,  1888. 

1  SEGLAS,  Lefons  sur  les  maladies  mentales  et  nerveuses,  1895,  p.  83. 


CHAPTER    XI 

THE   EVOLUTION   OP    TIC 

ri  iIC  is,  from  its  nature,  highly  variable  in  its  evolu- 
-L  tion ;  each  tic  has  a  development  peculiar  to 
itself.  Mental  differences  among  individuals  have  their 
counterpart  in  physical  differences,  in  health  as  well 
as  in  disease,  and  a  comprehensive  sketch  of  the  evolu- 
tion of  tic  is  therefore  impracticable.  We  shall  restrict 
ourselves  accordingly  to  a  few  general  remarks. 

In  the  great  proportion  of  cases  of  tic  the  onset 
is  an  insidious  one.  We  have  already  made  a  suffi- 
ciently detailed  examination  into  the  pathogenic 
mechanism  to  obviate  any  repetition  in  this  place,  but 
we  may  note  how  unsettled  the  earliest  manifestations 
are,  how  a  tic  may  pass  from  one  muscle  or  group  of 
muscles  to  another,  and  even  when  its  exciting  cause 
is  patent  an  apprentice  stage  always  precedes  its  final 
establishment.  Of  the  truth  of  this  the  history  of 
J.  provides  an  excellent  instance.  Another  one  is  from 
Pitres : 

A  nine-year-old  boy  received  a  severe  shock  one  day  through  being 
pounced  on  by  some  companions  who  were  in  hiding  behind  a  wood 
pile,  and  though  the  emotion  was  of  short  duration,  he  commenced 
a  few  days  later  to  exhibit  involuntary  muscular  twitches  of  the  upper 
part  of  his  body,  and  to  utter  suppressed  cries.  The  phenomena  increased 
in  violence  and  in  frequency,  and,  in  spite  of  treatment,  a  year 
later  he  was  not  freed  of  them  entirely.  For  an  unknown  reason  the 
tics  renewed  their  activity  when  he  was  seventeen  and  continued  so 
for  the  next  three  years,  until  a  spell  of  Pitres'  respiratory  exercises 
effected  a  complete  cure. 


222          TICS  AND   THEIR    TREATMENT 

An  evolution  such  as  the  above  may  be  considered 
more  or  less  typical  of  the  great  majority  of  tics. 

We  have  seen  that  the  tic  may  be  localised  in- 
definitely in  one  and  the  same  muscle  or  muscular 
group,  but  its  site  may  also  vary  from  day  to  day. 
Two  tics  may  coexist  and  coincide,  or  a  third  may 
appear  with  the  disappearance  of  the  others.  Unex- 
pected resurrections  may  succeed  periods  of  complete 
repose. 

Tic  always  shows  a  tendency  to  invade  ;  regarded 
as  a  functional  act,  it  moves  in  the  direction  of  greater 
complexity. 

After  involving  the  orbicularis,  for  instance,  a  tic  will  spread  to 
neighbouring  groups,  in  particular  to  those  muscles  whose  synergic 
contractions  form  a  special  expression  of  countenance.  That  is  why  tics 
of  the  eyelids  are  associated  with  movements  of  the  pyramidales,  frontales, 
and  corrugators.  Tics  of  the  lips  or  of  the  alae  nasi  very  commonly 
extend  to  the  corresponding  elevators.  It  is  not  surprising  that  muscular 
groups  accustomed  to  act  in  physiological  unison  should  also  be  affected 
together  (Noir). 

Moreover,  the  fecund  imagination  of  the  victim  to 
tic  is  calculated  to  facilitate  the  invention  of  all  sorts 
of  modifications,  complications,  parodies,  and  caricatures 
of  the  functional  acts  on  which  his  tics  are  grafted. 

Tics  are  constantly  varying  in  amplitude,  degree, 
and  frequency;  as  0.  remarked  spontaneously,  "  We  have 
our  good  days,  and  we  have  our  mauvais  quarts  d'heure." 
The  sedative  effect  of  rest,  solitude,  silence,  and  ob- 
scurity may  be  contrasted  with  the  detrimental  results 
of  fatigue,  noise,  fear  of  ridicule,  etc. 

However  incapable  S.  is  of  rotating  his  head  to  the  right  when 
requested  to  do  so,  the  movement  is  executed  with  the  utmost  readiness 
should  his  attention  be  drawn  in  that  direction.  But  if  he  hesitates, 
even  momentarily,  before  looking  round,  he  cannot  then  do  so  without 
the  preliminary  performance  of  all  sorts  of  contortions,  ending  in  a  twist 
of  his  body  through  a  half  circle  to  the  right.  Sometimes  he  actually 


THE  EVOLUTION  OF   TIC  223 

turns  round  two  or  three  times,  after  the  fashion  of  a  dog  chasing  its 
tail.  Let  him  have  a  pleasant  visit,  on  the  other  hand,  let  him  engage 
in  a  discussion,  or  be  engrossed  in  a  play,  let  him  administer  a  rebuke 
to  some  one,  and  immediately  his  trouble  is  forgotten,  his  speech  is 
accompanied  with  animated  gestures,  the  vicious  position  of  his  head 
vanishes — in  short,  he  becomes  normal. 

An  intercurrent  affection  may  act  either  as  a  deterrent 
or  as  a  stimulus ;  with  convalescence,  however,  there 
is  usually  a  re-establishment  of  the  mischief.  The  most 
potent  influence  over  the  phenomena  of  tic  is  wielded 
by  a  sense  of  well-being,  to  employ  Janet's  discrimina- 
ting expression.  Well-being  is  a  panacea  for  the 
tiqueur  no  less  than  for  the  hysteric.  The  tic  of  the 
worried  financier  disappears,  as  we  have  had  occasion 
to  note,  under  the  magic  of  a  rise  in  stocks  or  a  know- 
ledge of  solvency.  The  child's  happiness  is  bound  up 
in  his  freedom,  which  explains  the  cessation,  in 
Tissie's  little  patient,  of  all  convulsive  movements 
during  the  holidays. 

Much  evidence  is  forthcoming  to  support  these 
points,  but  we  must  admit  that  the  why  and  wherefore 
of  a  tic's  amelioration  or  aggravation  often  escape  us, 
nor  must  we  forget  that  both  in  the  child  and  the  adult 
spontaneous  cure  is  not  unknown. 

As  has  been  remarked,  the  evolution  of  tic  does 
not  lend  itself  to  systematic  description,  but  there  are 
cases  that  form  an  exception,  their  course  being 
regularly  progressive.  Strictly  speaking,  they  are  in- 
stances of  Grilles  de  la  Tourette's  disease. 

QILLES  DE   LA  TOURETTE'S  DISEASE 

Under  the  title,  "Study  of  a  nervous  affection 
characterised  by  motor  inco-ordination,  and  accompanied 
with  echolalia  and  coprolalia,"  Tourette l  grouped  to- 

1  GILLES  DE  LA  TOURETTE,  Archives  de  neurologie,  No.  25, 
1885,  p.  19. 


224          TICS  AND    THEIR    TREATMENT 

gether,  in  1885,  a  certain  number  of  cases  presenting 
features  in  common  and  so  enabling  him  to  describe  a 
morbid  entity,  specially  remarkable  for  its  progressive 
evolution.  He  was  followed  in  the  same  line  by  Guinon, 
who  supplied  an  account  in  nosographical  form,  and 
since  then  the  disease  has  figured  in  all  the  text-books. 

To  obtain  a  schematic  picture  of  the  condition  we 
shall  borrow  from  Tourette's1  last  communication  on 
the  subject: 

About  the  age  of  seven  or  eight  a  little  boy  or  girl — for  the  sexes  are 
affected  equally — commonly  with  a  wretched  family  history,  begins  to 
exhibit  a  series  of  tics.  The  attention  of  the  parents  is  soon  drawn 
to  the  fact,  but  they  seldom  give  much  heed  at  first,  since  the  twitches 
are  limited  perferably  to  the  facial  musculature.  At  this  stage,  too, 
expiratory  laryngeal  noises  are  occasionally  superadded. 

The  movements  may  be  confined  for  a  long  time  to  the  face,  but 
under  the  influence  of  causes  very  difficult  to  determine  they  gradually 
invade  the  shoulders  and  the  arms.  First  one  shoulder  is  shrugged  and 
then  the  other,  then  the  trunk  is  inclined  en  mane  to  right  or  left  ;  then 
the  patient  waves  his  hands  or  his  arms,  or  bends  backwards  and  forwards, 
or  jumps  up  and  down,  flexing  the  knees  alternately  and  tapping  with  his 
feet.  The  muscles  of  the  larynx  sometimes  participate  in  the  abnormal 
functioning,  whence  it  is  that  many  sufferers  from  tic  give  vent  to  quick 
expiratory  "  hems  "  and  "  ahs,"  which  coincide  often  with  the  twitches  of 
trunk  and  limbs. 

The  disease  may  be  limited  to  this  stage,  but  it  is  not  uncommon 
to  find,  a  few  months  or  years  after  the  beginning  of  the  facial  movements, 
that  the  inarticulate  laryngeal  sound  becomes  organised  and  develops  in  a 
particular  direction,  thus,  in  a  sense,  showing  a  pathognomonic  value. 
Under  the  influence  of  causes  whose  action  we  are,  in  the  majority  of 
cases,  powerless  to  appreciate,  the  patient  gives  vent  one  day  to  a  word 
or  short  phrase  of  a  quite  special  character,  inasmuch  as  its  meaning 
is  always  obscene.  These  words  and  phrases  are  exclaimed  in  a  loud 
voice,  without  any  attempt  at  restraint.  There  must  be  a  complete 
absence  of  the  moral  sense  where  there  is  coprolalia  such  as  this  ;  at 
the  moment  of  the  ejaculation  some  irresistible  psychical  impulse  must 
drive  the  patient  to  utter  filthy  words  unreservedly  and  with  no  con- 
sideration for  other  people. 

Another  psychical  stigma — echolalia — is  occasionally,  though  les» 
frequently,  observed  in  these  cases. 

1  GILLES  DE  LA  ToURETTE,  Semaine  mtdicale,  1899,  p.  153. 


THE  EVOLUTION  OF  TIC  225 

Such.,  then,  is  Gilles  de  la  Tourette's  disease,  a 
clinical  type  of  which  many  examples  have  been  re- 
corded. We  do  not  think,  however,  that  all  tics  can 
be  brought  under  the  same  category ;  we  lose  sight  of 
its  distinguishing  features  if  we  make  the  attempt.  Of 
course  fruste  and  atypical  cases  are  encountered,  but 
even  in  them  it  is  rare  not  to  find  a  certain  degree  of 
mental  instability  in  dependence  on  which  echolalia 
and  coprolalia  rest,  so  completing  the  morbid  syndrome, 
and  it  is  important  to  recognise  the  successive  develop- 
ment of  these  various  constituents. 

It  is,  indeed,  this  evolution  of  symptoms  which  is 
so  characteristic  of  Gilles  de  la  Tourette's  disease. 
A  careful  scrutiny  of  recorded  cases  of  tic,  however, 
makes  it  abundantly  clear  that  they  do  not  all  belong 
to  the  disease  of  convulsive  tics ;  their  localisation, 
form,  and  progress  are  so  different  that  the  effort  to 
assimilate  them  to  Tourette's  disease  would  abolish 
the  nosographical  value  of  the  latter.  One  patient 
may  have  an  ocular  tic  all  his  life,  and  nothing  else ; 
the  affection  of  another  may  be  limited  to  a  tic  of 
the  shoulder  and  arm ;  a  third  blinks  and  makes  a 
facial  grimace ;  a  fourth  is  a  coprolalic  who  has  never 
suffered  from  tic.  Are  they  all  to  be  considered  in- 
complete cases  of  the  disease  of  convulsive  tics?  To 
answer  in  the  affirmative  is  equivalent  to  a  failure  to 
appreciate  the  distinctive  characters  of  a  judiciously 
isolated  syndrome,  and  a  refusal  to  describe  tics  as 
they  are  met  with  in  everyday  life.  One  questions,  in 
fact,  whether  some  of  the  cases  allotted  to  Tourette's 
disease  really  conform  to  it.  Take  an  instance  from 
Chabbert1: 

A  woman,  aged  forty-two,  had  had  an  injury  to  the  left  side  of  her 
face  at  the  age  of  nine,  as  a  result  of  which  appeared  a  convulsive 

1  CHABBERT,  "  De  la  maladie  des  tics,"  Arch,  de  neurologic, 
1893,  p.  10. 

15 


226         TICS  AND    THEIR    TREATMENT 

facial  tic,  accompanied  at  times  by  hysterical  attacks  which  continued 
for  eight  years.  The  tic  itself,  an  abrupt  contraction  of  the  inferior 
portion  of  the  left  orbicularis  palpebrarum,  underwent  no  subsequent 
change,  in  degree  or  extent.  At  a  later  stage  a  fairly  definite  tendency 
to  coprolalia  became  manifest. 

An  unvarying  post-traumatic  palpebral  tic  in  an 
hysterical  subject  cannot  be  said  to  constitute  the 
syndrome  of  Gilles  de  la  Tourette,  in  spite  of  the 
coprolalia. 

In  another  of  his  cases  the  diagnosis  is  no  less  open 
to  doubt : 

The  son  of  the  previous  patient  was  a  youth  of  nineteen,  with  a 
bad  heredity  on  the  father's  side.  In  boyhood  he  had  been  a  somnambulist. 
Some  months  previously  to  his  coming  under  observation  he  developed 
a  convulsive  tic  limited  to  the  frontalis.  Stigmata  of  hysteria  were 
present  in  dyschromatopsia,  restriction  of  the  visual  fields,  and  left 
hemihyperaesthesia. 

A  third  case  reported  by  the  same  author  does 
probably  belong  to  the  disease  of  convulsive  tics  : 

A  woman  aged  forty-four,  of  a  strumous  diathesis,  exhibited  tics 
of  face  and  limbs,  occurring  in  the  form  of  attacks  sufficiently  violent 
to  cause  bruises,  attacks  which  were  invariably  associated  with  coprolalia. 
In  addition,  she  suffered  from  echolalia,  echokinesis,  zndfolie  du  doute. 

We  can  only  repeat,  of  course,  that  each  type  of 
tic  passes  by  insensible  gradations  into  others  that 
precede  it  or  succeed  it  in  the  hierarchy  of  tics ;  but  we 
must,  provisionally  at  least,  neglect  the  links  that  unite 
neighbouring  groups  if  we  are  to  avoid  losing  sight 
of  admittedly  distinctive  characters  in  too  compre- 
hensive summaries.  It  is  desirable  to  retain  the  term 
"disease  of  convulsive  tics"  for  those  cases  whose 
progressive  evolution  ends  in  the  generalisation  of  the 
convulsive  movements,  to  the  accompaniment  of 
coprolalia  and  sometimes  of  echolalia.  This  clinical 
form  represents  the  most  advanced  degree  attained  by 


THE  EVOLUTION  OF  TIC  227 

/ 

the  disease  ;  it  might  be  called  the  tic's  apogee.  From 
its  psychical  aspect,  moreover,  the  development  it 
undergoes  may  culminate  in  actual  insanity. 

According  to  the  teaching  of  Magnan,  the  disease 
of  convulsive  tics  does  not  constitute  an  entity,  since 
each  and  all  of  its  symptoms  may  occur  separately  as 
episodic  syndromes  of  degeneration.  The  general  con- 
siderations with  which  we  introduced  our  study  are 
applicable  in  this  connection,  and  we  shall  be  content 
to  say  with  Noir : 

We  cannot  deny  the  validity  of  the  objections  raised  by  Magnan 
and  his  school  ;  but  the  fact  that  these  various  symptoms  may  and  da 
most  frequently  occur  singly  is  no  reason  for  expunging  the  disease 
of  Gilles  de  la  Tourette  from  the  text-books.  The  combination  of  these 
symptoms  constitutes  a  clinical  entity  which  has  a  specific  evolution,, 
and  while  its  subjects  are  degenerates  in  the  sense  of  Magnan  and  of 
Charcot,  they  may  be  ranged  by  themselves  in  a  very  definite  group. 

In  some  cases  which  apparently  come  under  this 
category,  psychical  disturbance  has  not  been  a  prominent 
feature. 

Sciamanna l  is  the  reporter  of  a  case  where  a  young 
man  with  neuropathic  antecedents  was  afflicted  with  tics 
involving  various  muscular  groups ;  his  intellect,  how- 
ever, was  normal,  and  the  only  psychical  change  was 
an  insignificant  disorder  of  affectivity. 

In  such  a  case  it  would  be  instructive  to  know  the 
mental  condition  after  the  lapse  of  some  years. 

Two  typical  examples  of  Tourette's  disease  have 
been  described  by  Koster2  as  "disease  of  impulsive 
tics "  ;  a  third  case — in  which  widespread  muscular 
twitches,  the  muscles  of  respiration  and  the  cremasters 

1  SCIAMANNA,  Accademia  medico,  di  Roma,  1893. 

2  K6STER,    "  Ueber  die   Maladie  des    Tics    impulsifs,"    Deutsche 
Zeitschr.  f.  Nervenheilk.  1899,  p.  147. 


228         TICS  AND    THEIR   TREATMENT 

included,  were  coupled  with  sometimes  a  monotonous 
intonation  and  sometimes  a  jerky  speech,  though  psychi- 
cal functions  were  unimpaired — is  considered  by 
Kopczynski !  to  be  a  case  of  convulsive  tic,  which  he 
distinguishes  from  the  "  disease  of  convulsive  tics." 

A  last  instance,  published  by  Innfeld 2  as  a  case  of 
"  chronic  progressive  muscular  spasm,"  is  an  unmistak- 
able example  of  tic,  in  spite  of  the  author's  declaration 
that  it  does  not  correspond  to  any  known  morbid  type 
and  his  attempt  to  liken  it  to  chronic  chorea.  A  boy 
of  fifteen  exhibited  convulsive  movements  which  had 
begun  in  the  facial  musculature  and  thence  spread  to 
the  head,  shoulders,  and  hands,  and  were  accompanied 
with  respiratory  noises  and  involuntary  exclamations. 
There  was  no  alteration  in  sensation  or  in  reflectivity, 
or  in  electrical  excitability.  Sleep  banished  while 
emotion  aggravated  the  movements. 


VARIABLE  CHOREA  OF  BRISSAUD 

If  the  disease  of  Grilles  de  la  Tourette,  by  reason 
of  the  uniformity  of  its  symptomatology  and  the 
regularity  of  its  evolution,  justifies  its  differentiation 
as  a  separate  entity  among  the  tics,  a  comparison  of 
it  with  another  type,  of  polymorphic  manifestation, 
irregular  evolution,  and  uncertain  duration,  may  prove 
instructive.  We  refer  to  the  affection  described  by 
Brissaud  as  variable  chorea. 

The  form  of  the  motor  reactions  in  this  condition 
warrants  the  application  to  it  of  the  term  chorea,  but 
the  analogies  the  disease  presents  to  tic  are  very  close, 

1  KOPCZYNSKI,  "  Ein  Fall  von  Bewegungsneurose  in  Form  von 
Tic  convulsif,"  Gazela  Lekarska,  1900. 

1  INNFELD,  "  Ein  chronische,  progressive  Fall  von  Muskel- 
krampfen,"  Wien.  klin.  Wochenschr.,  1898,  p.  17. 


THE  EVOLUTION  OF  TIC  229 

nevertheless,  and  sometimes  the  two  occur  in  the  same 
individual.  Patients  suffering  from  variable  chorea 
reveal  the  same  mental  abnormalities  as  are  found 
among  those  who  tic,  while  the  troubles  of  motility 
are  sometimes  so  similar  to  what  we  meet  with  in  the 
latter  that  Gilles  de  la  Tourette  regarded  the  condition 
simply  as  one  form  of  convulsive  tic,  the  more  so  that 
it  is  occasionally  accompanied  by  explosive  utterance 
and  even  coprolalia. 

This  view,  however,  is  calculated  to  obliterate  the 
distinctive  characters  of  the  two  affections,  and  ought 
not  to  be  entertained.  We  cannot  do  better  than  repeat 
Brissaud's  original  description : 

The  use  of  the  word  chorea  need  occasion  no  ambiguity  :  the  chorea 
consists  in  the  appearance  of  meaningless  and  apparently  idiopathic 
involuntary  movements,  whose  repetition  during  rest  and  action  alike 
is  proof  of  their  irrationality  and  incongruity  ;  the  duration  of  the 
symptoms  may  be  limited  as  in  chorea  minor  or  Sydenham's  chorea, 
or  unlimited  as  in  chorea  major  or  Huntington's  chorea.  "  Variable " 
is  the  epithet  we  apply  to  the  chorea  because  of  the  lack  of  uniformity 
in  its  exteriorisation,  the  irregularity  of  its  development,  and  the  incon- 
stancy of  its  duration.  It  comes  and  goes,  waxes  and  wanes,  vanishes 
abruptly  to  reappear  unexpectedly  ;  it  is  a  neurosis  without  a  characteristic 
march. 

Notwithstanding  the  fact  that  we  are  dealing  with  a  chorea — that 
is  to  say,  with  a  disease  which  is  almost  as  readily  recognisable  by  the 
public  as  by  any  professional — the  difficulty  of  fixing  its  onset  is  paralleled 
by  the  difficulty  of  knowing  when  it  has  ceased.  This  uncertainty  is 
explained  by  the  facile  and  changeable  nature  of  the  patient  ;  until  the 
condition  is  revealed  by  unmistakable  signs  it  passes  for  an  insignificant 
muscular  caprice  of  no  pathological  importance,  while  its  disappearance 
is  not  associated  with  any  particular  modification  of  the  patient's  ways. 

There  is  a  natural  tendency  to  identify  all  "  nervous  movements " 
with  myoclonus,  but  the  conception  is  a  remarkably  nebulous  one, 
and  means  nothing  more  than  "  muscular  twitch."  On  the  other  hand, 
it  is  well  understood  that  "  nervous  movements  "  are  more  or  less  sudden 
movements  of  limbs,  shoulders,  face,  always  involuntary  and  generally 
increasing  in  force  and  frequency  with  the  nervous  state  of  the  patient. 

Parents  say,  for  instance,  that  their  child  has  become  more  restless 
and  irascible,  and  at  the  same  time  that  he  has  had  "  more  movements 
of  the  nerves."  The  coincidence  is  unfailing.  Is  the  expression  "  nervous 


230         TICS  AND   THEIR   TREATMENT 

movement "  lacking  in  precision  ?  Yet  it  signifies  what  it  is  intended 
to  signify.  We  are  concerned  neither  with  tonic  convulsions  nor  with 
clonic  spasms,  nor  yet  with  tics  of  habit  ;  what  the  term  stands  for 
is  a  complex  contraction,  brisk  but  not  violent,  closely  allied  to  the 
simplest  of  automatic  acts,  such  as  a  step  in  advance,  a  shrug  of  the 
shoulders,  a  frown,  a  sigh,  a  moan,  a  crack  of  the  fingers,  an  exclamation 
— in  any  case  usually  a  gesture  of  impatience.  The  whole  thing,  how- 
ever, is  so  variable  and  fugitive,  that  it  cannot  be  said  to  constitute 
a  definite  convulsive  phenomenon.  The  contractions,  further,  in  spite 
of  their  complexity,  escape  the  notice  of  their  originator,  who  is  quite 
surprised  at  being  asked  the  meaning  of  the  movement  he  has  just 
made,  as  he  is  almost  entirely  ignorant  of  it. 

Briefly,  the  "nervous  movements"  of  which  we  have  been  speaking 
do  not  belong  either  to  myoclonus  or  to  tic,  but  owe  their  distinctiveness 
to  their  multiplicity  and  inconstancy.  At  the  same  time  they  are  always 
grafted  on  a  certain  neuropathic  diathesis  akin  to  that  of  chorea  ;  in 
fact,  they  are  nought  else  than  a  form  of  chorea  themselves. 

The  psychical  peculiarities  of  the  patient  with 
variable  chorea  may  be  summed  up  in  instability  of 
thought  and  action,  combined  with  mental  infantilism. 
Hence  the  terms  "  polymorphous  chorea  "  and  "  chorea 
of  degenerates"  are  used  synonymously  for  variable 
chorea.1  Sometimes  the  disorders  of  the  mind  include 
hallucinations,  and  various  forms  of  phobia  or  mania. 

One  or  two  examples  may  be  given  : 

A  microcephalic  youth  of  sixteen,  a  monorchid,  developed  what 
appeared  at  first  to  be  an  ordinary  chorea  subsequently  to  an  orchidopexy. 
The  movements,  however,  varied  from  day  to  day  and  from  hour  to 
hour.  Sometimes  they  disappeared  for  days  at  a  time,  to  reappear 
suddenly  just  when  the  neurosis  seemed  cured.  The  influence  exerted 
on  them  by  the  will  was  both  mild  and  transient.  They  constituted,  in 
short,  a  particular  kind  of  chorea,  changing  and  changeable,  and  differing 
from  intermittent  chorea  in  that  neither  remissions  nor  relapses  were  ever 
wholly  complete.  Further,  the  condition  was  implanted  on  a  basis  of 
mental  and  physical  degeneration,  and  seemed  likely  to  become  established 
as  a  permanent  functional  stigma. 

In  another  case  a  peculiar  chorea  gradually  supervened,  for  no  obvious 
reason,  in  an  adult  female  of  tardy  and  imperfect  physical  and  intellectual 

1  PATRY,  "De  la  choree  variable  ou  polymorphe,"  These  de 
Paris,  1897. 


THE   EVOLUTION  OF  TIC  231 

development.  It  was  difficult  to  decide  whether  the  psychical  or  the 
somatic  phenomena  were  preponderant;  but  to  the  material,  tangible, 
and  visible  signs  of  constitutional  inferiority  was  superadded  a  choreiform 
instability  of  the  whole  voluntary  muscular  system,  consisting  in  agitation, 
gesticulation,  and  incorrigible  motor  restlessness,  coupled  with  a  con- 
spicuous incapacity  for  rational  action. 

The  steps  in  the  evolution  of  this  functional  defect  were  very  slow, 
and  coincided  with  final  confirmation  of  the  intellectual  insufficiency. 
As  for  the  chorea,  its  localisation  and  its  intensity,  its  increase  and  its 
decrease,  its  extension  and  its  limitation,  seemed  to  vary,  in  a  way 
that  could  not  be  foreseen,  at  the  call  of  certain  undetermined  circum- 
stances. 

In  a  third  instance  we  meet  with  many  of  the 
symptoms  already  noted  among  those  who  tic : 

X.  is  a  well-developed  boy  of  fifteen,  but  there  is  something 
peculiar  about  his  physiognomy  which  defies  analysis.  If  his  mother's 
statements  can  be  trusted,  he  is  intelligent,  quick,  witty,  sound  in 
judgment,  and  blessed  with  an  excellent  memory.  From  the  very  first 
he  has  been  eccentric,  timid,  and  hypersensitive,  and  is  to-day  as  tender- 
hearted and  affectionate  to  his  people  as  ever.  He  has  various  little 
"  manias "  of  his  own  ;  he  must  have  a  knife,  fork,  and  spoon  for 
himself,  and  cannot  take  his  food  in  comfort  if  they  have  been  set 
before  some  one  else.  Each  morning  he  dresses  himself  with  extreme 
deliberation,  then  comes  down  to  breakfast,  of  which,  however, 
he  will  not  partake  unless  he  has  touched  all  the  door  handles  on  his 
way.  This  little  matter  has  developed  into  an  obsession.  His  loathing 
of  cold  water  is  so  pronounced  that  his  morning  toilet  is  rather  a 
stormy  proceeding,  and  as  he  is  too  old  to  be  washed  by  his  mother, 
the  inevitable  result  is  that  his  face  and  hands  are  never  clean.  At 
school  he  is  both  attentive  and  docile,  finding  pleasure  in  his  study  of 
the  classics,  but  evincing  a  perfect  passion  for  German.  Anything 
German  is  a  source  of  ineffable  joy,  so  much  so  that  he  hugs  his 
dictionary  with  childish  exuberance.  He  listens  deferentially  to  his 
teachers,  but  takes  no  note  of  what  he  hears.  In  German,  Greek,  and 
Latin  he  is  at  the  head  of  his  class,  whereas  in  history  and  mathematics 
he  is  at  the  foot. 

The  "  nervous  movements "  for  which  he  has  been  brought  to  the 
consulting-room  consist  of  a  series  of  gesticulations  akin  both  to  tic 
and  to  chorea.  Some  are  much  more  frequent  than  others,  meaningless 
gestures  executed  spontaneously,  one  might  almost  say  unconsciously. 
As  he  walks  to  school  with  his  books  under  his  left  arm,  his  right  hand 
roams  over  his  person  ;  and  in  the  class-room  the  movements  are 


232          TICS  AND    THEIR    TREATMENT 

repeated.  At  table  he  rubs  his  back  against  the  chair,  and  alternately 
flexes  and  extends  his  right  leg.  Apart  from  these  "  habit  tics,"  he 
exhibits  actual  twitches  of  his  muscles  generally,  and  evidence  of  the 
consequent  disturbance  of  his  movements  is  furnished  by  a  glance  at 
his  untidy  bedroom,  his  disarranged  books,  his  blotted  papers,  his  slovenly 
clothes.  When  he  goes  out  with  his  parents,  he  is  never  at  their  side, 
but  lounges  along  in  his  own  way,  then  suddenly  hurries  to  regain  his 
place  by  them,  falling  back  again  and  occupying  himself  by  crossing 
his  legs,  knocking  his  ankles  together,  shrugging  his  shoulders,  grimacing, 
etc.  All  the  movements  can  be  arrested  for  a  time  by  an  effort  of 
the  will.  At  any  one's  behest  he  can  maintain  tranquillity  for  a  minute, 
but  the  strain  is  too  severe,  and  the  muscular  dance  recommences  sooner 
or  later. 

The  movements  are  highly  variable  in  type  and  degree,  nor  can 
the  mother  specify  the  date  of  their  appearance.  It  is  only  during  the 
last  three  years  that  her  attention  has  been  more  particularly  drawn 
to  them,  and  their  increasing  gravity  occasions  her  some  anxiety.  The 
boy  has  become  the  laughing-stock  of  his  companions  at  school,  hence  he 
limits  his  stay  there  to  the  actual  hours  of  his  classes. 

Three  years  later  the  choreic  symptoms  vanished.  X.  is  to-day  a 
stalwart  youth,  though  still  timid  and  eccentric.  It  is  evident  that 
in  his  case  the  variable  chorea  has  been  but  an  episode  in  adolescence, 
to  be  added  to  the  numerous  stigmata  of  degeneration  enumerated  above. 

Notwithstanding  its  slow  evolution  (says  Brissaud),  the  neurosis,  in 
so  far  as  it  was  a  disorder  of  motility,  seems  to  have  completely  dis- 
appeared. The  importance  of  this  for  prognosis  is  fundamental,  but 
from  the  point  of  view  of  diagnosis  it  is  no  less  significant,  seeing 
that  the  nature  and  form  of  the  movements  suggested  chronic  or 
Huntington's  chorea. 

A  case  described  by  Gilles  de  la  Tourette *  as  disease 
of  the  tics  seems  really  to  have  been  one  of  variable 
chorea. 

A  woman  of  twenty-two,  who  had  never  been  very  strong,  had  an 
attack,  at  eight  years,  of  involuntary  movements  of  face  and  arms  which 
prevented  her  feeding  herself,  and  at  the  hospital  a  diagnosis  of  chorea 
was  made.  Two  months  later  cessation  of  the  movements  allowed  of 
her  return  to  school,  but  a  second  attack  followed  after  two  years,  and 
a  third  a  year  later.  At  the  time  of  observation  she  was  in  the  throes 
of  her  sixth  relapse.  Every  one  who  had  seen  her  considered  the 
condition  as  chorea. 

1  GILLES  DE  LA  TOURETTE,  Semaine  medical*,  1899,  p.  153. 


THE  EVOLUTION  OF  TIC  233 

Tourette,  however,  was  dissatisfied  with,  the  diagnosis. 
There  was  no  suggestion  of  its  being  Sydenham's  chorea, 
or  hysterical  chorea,  still  less  of  its  belonging  to 
Huntington's  variety.  According  to  the  author,  the 
muscular  twitches  were  amorphous  and  indefinite, 
and  characterised  by  extreme  variability  in  form,  ex- 
pression, and  intensity. 

In  our  opinion  the  clinical  picture  is  that  of  vari- 
able chorea,  and  we  are  confirmed  in  our  opinion  by 
a  consideration  of  the  patient's  mental  condition. 

She  comes  of  a  pronounced  neuropathic  stock.  One  of  her  two 
sisters  is  nervous  and  impressionable,  and  probably  a  neurasthenic, 
while  the  other  is  subject  to  hysterical  attacks.  She  herself  is  of  a 
profoundly  nervous  temperament  ;  she  cannot  go  to  bed  without  assuring 
herself  several  times  that  no  one  is  concealed  beneath  it  ;  she  suffers 
from  fears  and  dreads  and  obsessions  of  all  sorts  ;  she  is,  in  fact,  an 
"  unstable,"  a  degenerate. 

In  one  of  our  patients  the  symptoms  were  unilateral, 
constituting  a  variable  hemichorea. 

It  is  a  matter  of  some  difficulty  to  furnish  an  adequate  description 
of  the  movements  of  the  right  arm.  We  note,  first  of  all,  that  their 
activity  depends  on  whether  the  arm  is  free  or  held  in  a  fixed  position. 
Voluntary  movements  are  carried  out  stiffly,  but  are  interrupted  by 
sudden  deviations,  sometimes  of  rather  a  wide  range,  and  highly 
irregular  in  distribution.  Notwithstanding  these  breaks,  the  end  to 
which  the  movement  is  directed  is  always  attained  with  precision. 

While  L.  was  an  apprentice  dressmaker,  she  occasionally  used  to 
make  various  contortions  with  her  arm,  though  if  her  attention  was  diverted 
they  did  not  occur,  and  as  a  matter  of  fact  she  did  her  work 
well  enough.  Once  she  became  familiar  with  the  mechanical  act  of 
sewing,  the  involuntary  performances  ceased.  Before  her  disease  asserted 
itself,  she  had  commenced  to  learn  the  piano,  and  she  continued  to  make 
unimpeded  progress,  as  her  teacher  discovered  a  method  of  holding  her 
elbow  which  checked  all  convulsive  twitches. 

The  involuntary  movements  of  the  right  leg  were  so  insignificant 
as  to  be  almost  negligible  ;  they  united  to  produce  a  sort  of  irregular 
tremor  which  became  appreciable  only  when  the  patient  was  very  tired 
or  very  annoyed.  Sometimes  a  long  walk  was  followed  by  a  certain 
hesitation  in  putting  the  right  foot  to  the  ground,  and  by  defective 


234         TICS  AND    THEIR   TREATMENT 

inhibition  of  the  antagonists  of  the  desired  movement.  Sometimes  one 
foot  was  knocked  against  the  other,  and  sometimes  the  right  appeared 
to  assume  an  equinovarus  position.  On  the  other  hand,  we  have  seen 
L.  walking  in  the  street  with  her  father,  when  no  anomaly  could  be 
detected  in  her  gait.  The  distraction  of  any  occupation  such  as  dancing 
or  playing  a  game  has  the  effect,  for  the  time  being,  of  banishing  the 
greater  part,  if  not  all,  of  the  spasmodic  phenomena. 

This  is  undoubtedly  a  case  of  Brissaud's  variable 
chorea  of  a  unilateral  type,  and  a  consideration  of  the 
symptoms  confirms  the  intimate  relationship  between 
it  and  tic. 

Various  intermediate  forms  have  been  noted.  In 
one  of  Brissaud's  cases,  variable  chorea  and  multiple 
tics  coexisted.  Fere  1  reports  a  case  of  variable  chorea 
preceded  by  tic,  and  Bernard  another  in  which  starting, 
trembling,  facial  tic,  variable  chorea,  etc.,  were 
associated. 

Tics  of  phonation  are  often  superadded  to  the 
gesticulations  of  variable  chorea.  Brissaud  refers  to 
the  case  of  a  girl  of  sixteen  in  whom  involuntary 
movements  resembling  those  of  this  type  of  chorea 
were  coincident  with  a  sort  of  hiccough,  and  a  more 
or  less  inarticulate  cry  ;  at  a  later  stage  the  movements 
became  very  infrequent,  the  hiccough  was  more  constant, 
and  the  cry  developed  into  a  coprolalic  ejaculation. 

Variable  chorea  and  variable  tic  are  obviously  very 
closely  allied.  The  movements  of  the  latter,  however, 
are  distinguished  by  their  greater  abruptness  and 
smaller  variety.  They  are  tics  by  reason  of  their 
systematisation  and  co-ordination ;  they  are  variable 
because  they  pass  from  one  region  of  the  body  to 
another.  There  is  no  necessary  relation  between  them ;  / 
each  has  an  individuality  of  its  own  and  is  independent 
of  the  rest.  In  variable  chorea,  on  the  other  hand, 

1  FERE,  "  Note  sur  un  cas  de  choree  variable,"  Nouv.  icon,  de  la 
Salpetriere,  1898,  p.  454. 


THE   EVOLUTION  OF  TIC  235 

one  movement  passes  insensibly  into  another,  and  the 
variants  of  any  particular  one  are  legion. 

However  easy  it  is,  then,  to  separate  the  two  clinically, 
it  is  none  the  less  true  that  they  spring  from  the  same 
soil  of  mental  defect.  Variable  chorea  differs  in  nature 
from  other  choreas,  though  its  form  is  the  same ;  it 
may  be  distinguished  from  tic  by  the  type  of  movement, 
but  in  essence  it  is  identical. 


STATE  NO 4* 41  S 
MANUAL  ARTS  .No  H,.,ut-  CCUMOMKS 

SANTA  8Affp.--.iu. 


CHAPTER    XII 

ANTAGONISTIC    GESTURES   AND   STRATAGEMS 

"I  T  OWE YEB  harmless  and  insignificant  a  tic  may 
JL-J-  be,  it  is  a  source  of  annoyance  to  its  subject 
of  which  he  constantly  seeks  to  disembarrass  himself. 
But  the  feebleness  of  his  will  militates  against  any 
sustained  effort,  and  if  for  a  brief  space  he  can  conserve 
his  immobility,  victory  eludes  his  grasp,  for  his  tics 
resume  the  offensive  and  increase  in  violence.  More 
than  ever  convinced  of  his  helplessness,  he  resorts  to 
measures  that  serve  but  to  accentuate  the  mischief. 
Thus  it  comes  to  pass  that  he  desists  from  his  attempts 
at  repression  and  admits  himself  vanquished. 

Some  there  are,  nevertheless,  whose  inventive  faculty 
leads  them  to  adopt  singular  attitudes,  to  execute 
curious  gestures,  to  utilise  elaborate  apparatus — pro- 
ceedings always  more  or  less  childish,  whose  employment 
is  usually  followed  by  success,  but  only  for  a  time. 
The  history  of  0.  acquaints  us  with  a  whole  series  of 
these  subterfuges,  for  which  the  expressive  name  of 
para-tics  was  invented  by  him,  tricks  intended  to  mask 
or  to  modify  existing  tics,  but  they  soon  themselves 
became  as  involuntary  and  as  inevitable. 

Not  all  who  tic  are  imaginative  enough  to  conceive 
such  plans,  and  many  have  no  thought  of  showing 
fight  at  all,  but  it  is  worth  while  dwelling  on  this  point 
for  a  little,  especially  in  view  of  the  frequency  with 

236 


ANTAGONISTIC  GESTURES  237 

which  certain  tics  are  accompanied  by  methods  of 
correction  evolved  by  the  patient. 

To  begin  with,  we  may  quote  the  case  of  mental 
torticollis.  The  sufferer's  head  is  irresistibly  driven  to 
the  right,  say,  yet  he  replaces  it  immediately  by  the 
mere  application  of  his  right  forefinger  to  his  chin, 
and  the  correct  attitude  is  maintained  so  long  as  the 
finger  is  applied.  Of  the  variants  of  this  efficacious 
antagonistic  gesture  the  most  common  is  the  grasping 
of  the  head  in  the  hands,  or  its  support  in  the  palm, 
or  the  simple  contact  of  the  fingers  with  chin,  or  cheek, 
or  temple.  In  some  cases  the  mere  threat  of  this 
gesture  suffices  for  the  purpose.  S.  approximates  his 
hand  to  his  left  ear,  but  before  he  has  actually  touched 
it  his  head  turns  spontaneously  to  the  right.  It  would 
be  difficult  to  find  more  conclusive  evidence  of  the 
purely  psychical  value  of  such  corrective  acts. 

Sometimes  the  resources  at  the  patient's  disposal 
are  confined  to  one  measure,  though  more  frequently 
he  avails  himself  of  several,  as  in  a  case  recorded  by 
Sgobbo.1  The  antagonistic  gesture  may  fail  of  its 
object  if  some  one  other  than  the  patient  put  it  to 
the  test.  Even  with  the  expenditure  of  considerable 
force  he  may  make  no  impression  on  the  tonic 
contraction ;  this  rule,  however,  is  by  no  means 
general. 

One  of  our  patients,  whose  head  used  to  be  strongly 
tilted  on  to  his  elevated  right  shoulder,  while  his  right 
arm  was  flexed,  his  left  shoulder  depressed,  and  his 
whole  trunk  deviated  to  the  former  side,  was  able 
instantaneously  to  resume  his  normal  attitude  by  merely 
placing  his  thumbs  one  on  either  side  of  his  head.  If 
any  one  else  sought  to  correct  his  vicious  position  he 
could  do  so  by  applying  his  fingers  to  two  well-defined 

1  SGOBBO,  "  Un  caso  di  torcicollo  mentale,"  II  manicomio  modemo, 
1898,  p.  424. 


238          TICS  AND    THEIR    TREATMENT 

spots  on  the  occiput,  towards  the  base  of  the  mastoid 
processes.1 

Occasionally  the  antagonistic  gesture  is  of  the  nature 
of  a  paradox.  We  may  cite  an  example  from  Raymond 
and  Janet.2 

If  we  ask  the  patient  whether  she  cannot  sometimes  prevent  her 
head  from  rotating,  she  declares  she  can,  and  demonstrates  how  it  is  done 
by  lightly  touching  her  forehead  with  her  finger  tips.  Now,  in  view  of 
the  fact  that  her  head  is  deviated  to  the  left  and  backwards,  it  will  be 
seen  that  no  pressure  exerted  in  front  could  obviate  this.  What  really 
happens  is  that  at  the  moment  of  contact  not  only  does  she  inhibit  the 
movement  by  the  aid  of  her  will,  but  she  also  makes  a  slight  forward 
inclination  of  her  head  to  rest  it  on  the  point  of  support.  No  performance 
of  this  description  could  have  any  efficacy  in  the  case  of  a  genuine  spasm 
due  to  irritation  on  a  reflex  arc. 

At  length  the  day  arrives  when  the  hand  is  unequal 
to  the  task,  and  the  patient  endeavours  to  utilise  more 
resistant  bodies,  such  as  the  back  of  a  chair  or  the  wall 
of  the  room,  as  in  a  case  of  retrocollis  reported  by 
Brissaud.  These  devices  in  their  turn  prove  insufficient, 
and  relief  is  obtained  only  in  the  recumbent  position. 
Fournier3  has  seen  a  case  of  convulsive  twitching  of 
the  right  sternomastoid  and  trapezius  arrested  when 
the  head  was  reclining  on  a  pillow. 

Even  in  bed,  however,  there  is  usually  something 
to  complain  of:  the  pillow  is  too  high,  or  too  low,  or 
too  soft ;  the  rustle  of  the  packing  is  disagreeable,  the 
sheets  are  too  rough,  etc.,  etc.  It  is  then  that  all  sorts 
of  unlikely  arrangements  are  adopted,  and  the  patient 
puts  his  head  under  the  bolster,  or  lets  it  hang  over 
the  edge  of  the  bed,  or  piles  up  additional  cushions 
and  mattresses  calculated  to  retain  it  in  the  desired 
situation. 

1  FEINDEL  AND  MEIGE,  "  Quatre  cas  de  torticolis  mental,"  Arch, 
gin.  de  medecine,  January,  1901,  p.  61. 

1  RAYMOND  AND  JANET,  Nevroses  et  idees fixes,  vol.  ii.  p.  377. 
1  FOURNIER,  "Tic  rotatoire,"  These  de  Strasbourg,  1870. 


ANTAGONISTIC  GESTURES  239 

Frequently  the  stratagems  are  highly  ingenious  and 
complicated. 

Madame  K., l  forty-three  years  of  age,  suffers  from  clonic  movements 
of  the  head  which  disappear  with  the  adoption  of  a  torticollic  attitude, 
the  face  looking  to  the  left.  Nothing  is  easier  than  voluntarily  to  correct 
this  attitude,  but  the  clonic  movements  at  once  reassert  themselves,  although 
they  may  momentarily  be  kept  in  abeyance  by  placing  the  hand  on  the 
chin. 

Numerous  and  ingenious  have  been  the  devices  framed  by  this  lady, 
but  in  no  instance  has  their  success  been  other  than  transient.  Her 
latest  invention  is  a  stiff  high  collar  fashioned  of  several  thicknesses  of  a 
heavy  material.  At  the  risk  of  strangling  herself  she  has  so  compressed 
her  neck  that  no  movement  is  possible,  but  the  right  arm  has  now  become 
the  seat  of  action. 

A  patient  of  Grasset 2  used  to  promenade  in  the 
grounds  of  the  hospital  holding  a  cane  in  his  teeth 
and  maintaining  his  head  in  position  by  keeping  one 
finger  on  the  end  of  the  stick. 

Another  patient,  under  the  care  of  Nogues  and  Sirol,3  whose  head 
was  fixed  in  irresistible  anteroflexion  and  rotation  to  the  left,  had  invented 
a  most  elaborate  piece  of  apparatus,  the  adoption  of  which  was  followed 
by  perfectly  satisfactory  results.  On  the  frame  of  a  pair  of  pince-nez 
deprived  of  the  glasses  he  fixed  a  piece  of  iron  wire  ten  centimetres  long 
in  such  a  way  that  it  stood  out  from  the  spring  at  right  angles  to  the 
plane  of  the  pince-nez.  It  was  sufficient  to  wear  this  thing  on  his  nose 
to  inhibit  the  spasm,  and  to  be  able  to  talk,  walk,  do  anything  unhampered 
by  his  torticollis  ;  it  was  not  even  necessary  to  concentrate  his  gaze  on 
the  extremity  of  the  rod. 

In  the  case  of  one  of  our  patients,  N.,  whose  head 
we  had  on  several  occasions  succeeded  in  keeping 
straight  while  he  was  writing  by  directing  a  pin  towards 

1  FEINDEL  AND  MEIGE,  "  Quatre  cas  de  torticolis  mental,"  Arch.  gen. 
de  medecine,  1901,  p.  61. 

*  GRASSET,  "Tic  du  colporteur,"  etc.,  Nouv.  icon,  de  la  Salpetriere, 
1 897,  p.  217. 

3  NOGUES  AND  SIROL,  "  Un  cas  de  torticolis  mental,"  Nouv.  icon,  de 
la  Salpetriere,  1899,  p.  82. 


240          TICS  AND    THEIR   TREATMENT 

his  left  cheek,  the  idea  was  entertained  of  utilising  this 
procedure  out  of  doors,  and  accordingly  a  long  pin  was 
fixed  in  the  collar  of  his  overcoat.  There  never  was 
the  slightest  prick  on  his  cheek,  but  we  strongly  dis- 
suaded him  from  the  continuation  of  this  objectionable 
practice. 

Antagonistic  stratagems  of  this  kind  are  met  with 
in  other  tics. 

A  curious  case  of  mental  trismus  is  reported  by 
Raymond  and  Janet,1  where  the  patient  always  spoke 
through  his  clenched  teeth,  but  opened  his  mouth 
widely  enough  when  showing  his  tongue  or  when  eating. 
To  overcome  the  tonic  contraction  of  his  masseters  he 
used  to  insert  a  minute  piece  of  cork  between  his  jaws, 
though  he  could  also  open  them  to  articulate  properly 
by  holding  his  chin  with  his  hand. 

Chatin's  patient 2  nullified  the  permanent  contraction 
of  his  masticatory  muscles  by  insinuating  his  little  finger 
between  the  dental  arches. 

In  this  connection  reference  may  again  be  made  to 
the  fixation  attitude  adopted  by  young  J.3  for  his 
left  arm,  a  subterfuge  of  his  own  invention  which  he 
considered  a  sovereign  remedy.  In  essence  it  was 
nothing  else  than  an  efficacious  antagonistic  gesture, 
inspired  by  a  tic  and  become  its  indispensable  comple- 
ment. Of  other  ingenious  ideas  of  his  brief  mention 
may  be  made. 

Convinced  of  the  necessity  and  possibility  of  checking  the  movements 
of  his  shoulder,  he  sought  the  aid  of  his  "  immobilising  mattress,"  an 
ordinary  mattress  spread  in  a  corner  of  the  dining-room,  on  which  he 
flung  himself  and  reclined  from  morning  to  night,  making  the  wretched 
thing  his  companion,  solace,  and  confidant,  who  alone  understood  and 

1  RAYMOND  AND  JANET,  Nevroses  et  idees  fixes,  vol.  ii.  p.  381. 

*  CHATIN,  "Note  sur  un  cas  de  trismus  mental,"  Rev.  neuro- 
logtque,  1900,  p.  310. 

'  MEIGE,  "  Histoire  d'un  tiqueur :  tics  variables,  tics  d'attitude," 
Journ.  de  med.  et  de  chir.  pratiques,  August  25,  1901. 


ANTAGONISTIC  GESTURES  241 

could  alleviate  his  tics.  In  his  anxiety  to  find  some  point  of  resistance 
for  his  left  arm  to  work  against,  he  had  a  second  and  much  narrower 
mattress  put  under  the  first,  so  that  prodigious  efforts  were  required  on 
his  part  to  maintain  equilibrium  on  the  cylindrical  surface.  This  was 
exactly  what  he  desired,  and  for  a  time  he  ceased  to  tic. 

An  equally  curious  case  is  that  of  one  of  Raymond 
and  Janet's  patients  afflicted  with  multiple  tics.1 

He  was  a  man  thirty  years  old,  who  denied  having  had  tics  for  more  than 
four  years  ;  he  had  always  been  eccentric,  however,  and  came  of  a  family 
some  of  whose  members  were  dullards  and  others  hysterics.  His  career 
at  school  and  college  was  brilliant,  but  his  vain  and  erratic  disposition 
had  prevented  him  from  realising  his  boundless  ambitions,  and  carrying  / 
into  effect  many  ingenious  schemes.  For  that  matter,  a  prominent  trait 
in  his  character  was  a  curious  scrupulousness  that  led  him  to  seek  an 
impossible  perfection  for  all  his  actions.  Anything  he  put  his  hands  to 
he  thought  might  be  better  accomplished  if  he  had  a  system  for  the 
purpose  ;  he  had,  for  instance,  all  sorts  of  plans  for  improving  his  cali- 
graphy,  for  holding  the  pen,  interminable  "  tips  "  for  correct  punctuation, 
for  learning,  for  reciting.  To  such  an  extent  was  he  embarrassed  by 
these  procedures  that  he  could  not  write  two  letters  consecutively. 
Purposeless  voyages  to  Africa  ended  in  his  contracting  conjunctivitis, 
malaria,  and  dysentery,  and  he  returned  to  France  worn  out  and  more 
eccentric  than  ever.  Thereafter  the  state  of  his  health,  and  above  all  his 
functions  of  respiration  and  digestion,  became  matters  of  absorbing 
attention.  A  system  had  to  be  thought  out  for  breathing  better  and  for 
avoiding  possible  suffocation.  He  next  devoted  himself  to  the  question 
of  alimentation,  and  conceived  the  idea  of  moistening  each  mouthful  of 
food  with  water,  soon  finding  it  desirable  to  wet  his  lips,  apart  from  meal 
time,  in  order  to  breathe  better.  One  day  during  a  journey  by  train  he 
suffered  agonies  from  want  of  his  drop  of  water. 

Examples  such  as  these  serve  to  illustrate  how  the 
misplaced  ingenuity  of  the  sufferer  from  tic  complicates 
his  misfortunes  instead  of  banishing  them,  and  indicate 
to  what  extremes  his  eagerness  to  obtain  respite  may 
lead  him. 

All  these  gestures  and  stratagems  may  be  considered 
as  manifestations  of  ideas  of  defence,  comparable  to 
what  obtains  among  those  afflicted  with  obsessions  and 
delusions  of  persecution. 

1  RAYMOND  AND  JANET,  Nevroses  et  idees  fixes,  vol.  ii.  p.  385. 

16 


CHAPTER    XIII 

THE   COMPLICATIONS    OF   TIC 

FOLLOWING  in  the  train  of  the  tics  may  come  a 
number  of  complications,  insignificant  enough  as 
a  general  rule,  the  dread  of  which  may  in  some  cases 
actually  be  instrumental  in  stimulating  the  will's 
activity  to  rid  the  patient  of  his  tic. 

Dislocations  have  in  violent  cases  been  known  to 
occur.  Incessant  repetition  of  a  tic  may  lead  alike  to 
hypertrophy  of  certain  muscles  and  atrophy  of  their 
antagonists,  conditions  which  in  aggravated  instances 
may  produce  permanent  malformation. 

It  is  of  course  in  cases  of  spasm  and  other  convulsive 
phenomena  dependent  on  structural  disease  of  nerve 
centres  or  conductors  that  such  trophic  disturbances 
are  most  liable  to  occur.  Gaupp  J  has  described  a  case 
of  partial  congenital  myotonia  localised  in  the  muscles 
of  the  forearm  and  hand,  and  associated  with  atrophy, 
in  a  patient  presenting  certain  stigmata  of  infantilism ; 
but  the  condition  can  scarcely  be  classed  with  the  tics. 

As  for  actual  paralysis  supervening  on  a  tic,  the 
case  recorded  by  Grasset 2  of  a  young  girl  in  whom  a 
tic  of  the  right  leg  was  succeeded  by  a  trailing  move- 
ment of  the  same  limb  in  walking  can  hardly  be 
considered  conclusive,  inasmuch  as  such  incidents 

1  GAUPP,  Centralb.f.  Nervenheilk.,  February,  1900. 
1  GRASSET,  Clinique  mtdicale,  1891. 


THE  COMPLICATIONS   OF  TIC  243 

usually  indicate  hysteria  or  functional  disturbances 
akin  to  tonic  tics. 

Biting  tics  are  more  apt  to  be  accompanied  by 
various  sequelae,  such  as  mutilations,  excoriations, 
ulcerations  of  all  sorts.  By  constant  nibbling  at  his  lip 
J.  produced  an  erosion  of  the  mucous  membrane,  which 
became  infected  and  developed  into  an  ulcerative 
stomatitis.  The  accident,  however,  had  a  salutary 
effect  on  his  tic. 

"We  may  quote  another  illustration  from  the  history 
of  the  same  patient  to  show  how  complications  may 
sometimes  be  of  curative  value. 

In  January,  1901,  in  consequence  of  excessive  cudgelling  of  one 
fist  by  the  other,  the  back  of  the  left  wrist  became  inflamed  and  painful, 
but  the  bruise  soon  disappeared.  In  April  of  the  same  year,  however, 
a  large  reddish  ecchymosis  made  its  appearance  in  the  neighbourhood 
of  the  left  elbow,  with  a  painful  swelling  of  the  whole  arm  on  the 
proximal  side,  and  a  few  days  later  the  discovery  of  a  hard,  cordlike 
mass  along  the  border  of  the  biceps  made  it  clear  that  phlebitis  had  set 
in.  With  proper  treatment  the  symptoms  gradually  diminished  in  in- 
tensity, but  there  can  be  no  doubt  of  their  origin  in  the  reiterated 
violence  of  J.'s  onslaught  on  his  left  arm. 

The  immediate  outcome  of  the  event  was  to  put  a  brake  on  his 
exuberant  gestures,  and  although  the  impulse  was  still  sometimes 
urgent  enough  to  tempt  him  to  recommence,  the  thought  of  his  phlebitis 
and  fear  of  the  dangers  of  a  relapse  were  sufficient  to  recall  him  to  his 


Apropos  of  complications  the  case  of  0.  occurs  to 
the  mind,  his  biting  tics  ending  in  the  premature  loss 
of  all  his  teeth,  while  his  habit  of  rubbing  his  nose  and 
his  chin  against  the  back  of  a  chair  led  to  the  de- 
velopment of  callosities.  Tonic  tics  of  the  neck 
may  in  cases  of  long  duration  result  in  permanent 
deformities. 

Apart  from  such  complications,  the  vast  majority 
of  the  accidents  that  accompany  tics  are  attributable 
to  various  concurrent  affections.  A  case  reported  by 


244         TICS  AND   THEIR    TREATMENT 

Fer6  1  of  rotatory  movements  of  the  head  passing  some 
years  later  into  the  initial  symptom  of  epileptiform 
convulsions  ought  not,  in  all  probability,  to  be  placed 
among  the  tics. 

As  for  the  grave  mental  affections  that  sometimes 
are  superadded  to  long-standing  tics,  it  is  unjustifiable 
to  class  them  as  complications ;  they  are  rather  mani- 
festations of  psychical  instability  that  have  found  a 
suitable  medium  for  their  evolution  ;  in  many  instances 
they  occur  quite  independently  of  the  tics. 

It  may,  however,  be  remarked  that  the  persistence 
of  a  tic  entails  ceaseless  preoccupation  on  the  part  of 
the  subject,  and  may  thus  pave  the  way  for  obsessions 
or  hypochondriacal  ideas.  The  motor  disturbance  reacts 
adversely  on  the  mental  state  of  which  it  is  the  out- 
come. Hence  an  obsession  may  give  rise  to  a  motor 
display  that  has  all  the  appearance  of  a  tic,  while 
the  motor  act  in  its  turn  may  become  an  actual 
obsession. 

1  FERE,  "  L'epilepsie  et  les  tics"Journ.  de  neurologie,  1900,  p.  309. 


CHAPTER  XIV 

THE  RELATION  OP  TICS  TO  OTHER  PATHOLOGICAL 
CONDITIONS 

AVAST  number  of  disturbances  of  motility,  dis- 
tinguished as  spasm,  chorea,  cramp,  myoclonus, 
myotonia,  etc.,  may  be  derived  from  the  same  patho- 
logical substratum  as  tic,  and  an  equally  vast  number 
of  psychical  anomalies  may  spring  from  that  psycho- 
pathic diathesis  of  which  tic  is  merely  the  motor 
expression. 

The  frequency  of  these  associations  is  confirmed 
by  innumerable  clinical  observations,  many  instances  of 
which  have  been  given  already. 

That  the  relations  between  tic  and  other  diseases 
of  the  nervous  system  are  very  intimate  is  patent  from 
every-day  experience ;  such  and  such  a  tic  may  be 
succeeded,  in  the  same  individual,  by  a  much  graver 
condition  in  the  shape  of  mental  disease,  general  para- 
lysis, tabes  dorsalis,  etc.  Inversely,  some  cases  of  chorea 
seem  to  terminate  by  leaving  no  trace  of  their  occurrence 
beyond  some  little  convulsive  movement  or  tic.  The 
position  tic  occupies  is,  then,  a  peculiarly  interesting 
one,  for  it  may  be  the  starting-point  of  another  affection, 
it  may  be  an  intercurrent  phenomenon,  or  it  may  persist 
as  the  reminder  of  some  previous  disease.  For  this 
reason  it  well  merits  attentive  study. 

In  this  chapter  we  shall  examine  the  connections 
of  tic  with  hysteria,  neurasthenia,  epilepsy,  mental 
disease,  and  idiocy  respectively. 

245 


246         TICS  AND   THEIR   TREATMENT 

TICS  AND  HYSTERIA 

Our  response  to  the  question  whether  tics  are 
hysterical  in  origin  is  a  direct  negative.  Without 
attaching  pathognomonic  significance  to  stigmata,  we 
may  remark  how  seldom  they  are  encountered  among 
those  who  suffer  from  tic,  and  how  rarely  the  latter 
exhibit  any  of  the  paroxysmal  manifestations  of 
hysteria. 

Modifications  of  general  sensibility  such  as  anaBs- 
thesia  or  hypersesthesia  are  unknown ;  the  special 
senses  are  intact ;  in  particular,  contraction  of  the 
visual  fields  is  never  met  with.  Though  these  signs 
are  negative,  their  importance  from  the  point  of  view 
of  diagnosis  is  none  the  less  real. 

The  mental  condition  of  patients  with  tic  is  no 
doubt  analogous  to  that  of  hysterical  cases,  but  it  is  no 
less  common  in  many  others  that  present  no  sign  of  that 
neurosis.  There  is  little  or  nothing  in  tic  characteristic 
of  hysteria,  and  one  sometimes  questions  whether  the 
aoi-disant  hysteria  of  certain  subjects  of  tic  is  the 
real  disease. 

In  the  same  way  as  all  who  are  predisposed,  the  sufferer 
from  hysteria  may  develop  a  tic  or  tics,  and  although 
tic  was  held  by  Briquet,  Axenfeld,  Bouchut,  and  others, 
to  be  merely  an  accessory  symptom  of  hysteria  and 
nervosism,  these  doctrines  were  propounded  prior  to  the 
analytic  researches  of  Charcot. 

Pitres,1  whose  opinion  is  so  weighty  in  matters 
neurological,  considered  a  predisposition  to  tic  as  a  sign 
of  hysteria,  for  which  neurosis  the  subjects  of  tic  were 
candidates,  and  supported  his  contention  by  various 
clinical  examples : 

A   resin -gatherer  of   Landes   carried    all   day  from   tree    to    tree    a 
1  PITRZS,  Lemons  sur  rhysterie,  vol.  i.  p.  317. 


OTHER  PATHOLOGICAL   CONDITIONS   247 

notched  stake  of  wood  by  which  to  climb  up  the  pine-trunks.  The 
weight  of  it  on  his  left  shoulder  began  to  cause  a  slight  but  persistent 
aching,  which  was  followed  by  involuntary  deviation  of  the  chin  to 
that  side.  The  movements  took  place  at  the  rate  of  ten  to  thirty  a 
minute,  but  diminished  materially  in  frequency  and  degree  whenever 
the  patient  lay  on  his  left  side,  or  when  he  inclined  his  head  voluntarily 
on  either  shoulder,  and  disappeared  entirely  if  he  was  asleep,  or  if  he 
sang,  or  whistled,  or  recited  in  a  loud  voice. 

Examination  of  his  visual  fields  revealed  a  marked  restriction,  and 
every  effort  to  cure  the  condition  proved  ineffectual. 

Pitres'  conclusion  is  that  the  condition  is  one  of  tic, 
probably  caused  by  the  habit  of  carrying  the  stake,  and 
probably  also  of  hysterical  origin.  It  is  true  the  hysteria 
is  reduced  to  its  most  simple  elementary  symptomatic 
expression,  but  it  is  difficult  not  to  recognise  its  activity 
in  the  concentric  contraction  of  the  fields  of  vision. 

Nothing  is  more  likely,  we  think,  than  that  we  are 
dealing  in  this  instance  with  a  tic  occasioned  by  a 
professional  act,  but  we  doubt  whether  alterations  in 
the  visual  field  are  sufficient  to  justify  a  diagnosis  of 
hysteria. 

In  another  case  of  the  same  author,  where  a  facial 
tic  made  its  appearance  in  a  hystero-neurasthenic  after 
a  series  of  worries,  the  association  of  the  two  is  of 
course  undeniable,  but  it  does  not  follow  that  tic  is 
in  essence  hysterical. 

Take  another  example  from  Chabbert : 

A  little  girl  of  twelve  years,  with  a  bad  family  history,  began  to 
exhibit  involuntary  movements  as  the  result  of  a  succession  of  frights, 
which  led  at  the  same  time  to  the  production  of  certain  hysterical 
phenomena.  The  stigmata  were  unmistakable,  and  in  addition  the 
girl  was  an  echolalic. 

Here  there  seems  to  have  been  a  combination  of 
hysteria  with  the  disease  of  convulsive  tics.  Charcot,1 

1  CHARCOT,  Lemons  du  mardi,  October  23,  1888. 


248          TICS  AND    THEIR    TREATMENT 

however,  drew  a  sharp  line  of  distinction  between  them, 
although  they  may  co-exist  in  the  same  individual. 

Apropos  of  this  subject  Raymond  and  Janet  *  call 
attention  to  the  fact  that  in  the  somnambulistic  state 
the  memory  may  be  much  more  extensive  than  in  the 
waking  state,  and  may  recall  events  that  have  not 
passed  the  threshold  of  consciousness,  which  neverthe- 
less have  been  the  determining  cause  of  various 
phenomena  of  the  conscious  life.  In  this  way  may  be 
explained  the  genesis  of  certain  tics,  although  it  is  not 
a  necessary  sequel  that  they  themselves  are  stigmata 
of  hysteria. 

Sometimes,  however,  that  disease  does  appear  to 
play  an  indispensable  part  in  originating  convulsive 
movements.  An  interesting  case  in  point  has  been 
published  by  Scherb  2  as  "  beggar's  tic." 

The  patient  is  a  young  girl  eighteen  years  old,  born  of  an  alcoholic 
father  and  an  hysterical  mother,  and  brought  up  amid  deplorable  sur- 
roundings, socially  and  morally.  At  the  age  of  seven  she  contracted 
diphtheria,  and  a  doctor  was  called  to  visit  her.  The  mere  sight  of 
him  so  frightened  her  that  the  whole  of  the  right  side  of  her  body 
went  into  a  state  of  contracture,  with  mouth  and  eye  deviated 
to  the  right,  the  arm  pronated  and  adducted,  the  leg  stiff  and  the 
heel  raised  off  the  ground.  Some  gradual  improvement  took  place  after 
a  month,  but  her  mother  saw  in  the  incident  a  means  of  attracting 
public  sympathy,  and  encouraged  the  child  to  maintain  the  vicious 
attitude  by  sending  her  into  the  streets  to  beg.  And  so  she  appears 
to-day,  her  right  foot  trailing,  her  toes  flexed,  her  forearm  bent,  her 
hand  extended  and  ringers  curled  up.  Whenever  the  patient  is  unobserved 
or  forgets  her  professional  attitude,  at  once  the  arm  resumes  its  normal 
position  and  activity. 

An  examination  of  sensation  reveals  a  hyperaesthesia  of  the  right  half 
of  the  body,  with  points  douloureux  over  the  left  ovary  and  the  left 
mamma,  as  well  as  over  the  larynx.  There  is  no  contraction  of  the 
visual  fields  ;  reflectivity  is  normal  ;  Babinski's  sign  is  absent. 

1  RAYMOND  AND  JANET,  Nevroses  et  idces  fixes,  vol.  i.  p.  397. 

1  SCHERB,  "  Hfimispasme  tonique  du  cot6  droit  constituant  un  tic 
mental  professionnel :  tic  de  la  mendiante,"  Soc.  de  neur.  de  Paris, 
May  3,  1900. 


OTHER  PATHOLOGICAL   CONDITIONS    249 

The  author  considers  the  case  one  of  "  professional 
mental  tic  "  in  a  predisposed  patient — in  other  words, 
the  tic  is  a  "  mental  bad  habit "  in  an  individual 
psychically  abnormal. 

There  is  a  certain  analogy  between  this  condition 
and  mental  torticollis  in  the  insignificance  of  the  effort 
by  which  the  patient  corrects  the  deformity,  compared 
with  the  great  force  exerted  by  any  one  else  to  obtain 
the  same  result.  Yet  the  symptoms  strongly  suggest 
hysteria ;  their  unilaterality,  and  the  combination  of 
motor  and  sensory  alterations,  are  altogether  too 
special  to  have  been  caused  by  any  other  morbid 
process. 

Of  course  everything  depends  on  the  exact  inter- 
pretation to  be  put  on  the  word  hysteria.  As  far 
as  we  are  concerned,  to  consider  a  symptom  of  hysterical 
origin  because  it  seems,  to  be  purely  functional  is  sadly 
to  misunderstand  the  question.  The  absence  of  what 
we  call  organic  signs  is  a  negative  feature  common  to 
all  neuroses,  each  of  which,  hysteria  included,  ought  to 
have  definitely  fixed  limits. 

According  to  Babinski,1  hysteria  is  a  mental  state 
which  renders  its  subject  capable  of  auto-suggestion. 
The  distinguishing  mark  of  the  condition  is  that  its 
symptoms  may  be  reproduced  with  mathematical 
accuracy  by  suggestion,  and  may  by  similar  means  be 
made  to  disappear. 

Now,  while  auto-suggestion  may  undoubtedly  be  a 
factor  in  the  evolution  of  tic,  it  is  rather  too  much  to 
maintain  that  an  "  evil  suggestion "  may  constitute 
a  tic  by  itself,  and  we  question  whether  the  influence 
of  persuasion  alone  will  suffice  to  bring  about  a  cure. 
Nothing  short  of  re-education,  faithfully  practised  for 
months  and  years,  will  produce  any  effect,  and  even  this 

1  BABINSKI,  "Definition  de  Physterie,"  Soc.  de  neur.  de  Paris, 
November  7,  1901. 


250          TICS  AND    THEIR    TREATMENT 

method  seldom  results  in  more  than  a  progressive 
amelioration.  Sudden  cures  are  familiar  in  hysteria, 
but  unknown  in  tic.  Treatment  by  hypnotism  is  rarely 
successful  unless  the  patient  is  also  a  full-fledged 
hysteric,  and  this  is  quite  the  exception. 


TICS  AND  NEURASTHENIA 

The  relations  between  tic  and  neurasthenia  need 
not  detain  us.  Neurasthenic  and  tiqueur  alike  may 
suffer  from  aboulia,  obsessions,  and  nosophobia,  and 
the  same  depressive  causes  may  favour  the  establish- 
ment of  the  two  diseases ;  but  this  is  true  of  any  form 
of  psycho-neurosis.  To  identify  the  one  with  the  other 
is  to  misinterpret  the  physical  signs  of  the  condition 
as  described  by  Beard.  The  term  neurasthenia  has 
been  so  badly  abused  that  its  fundamental  symptoms 
have  been  lost  sight  of.  Yet  the  polymorphic  nature 
of  these  symptoms  is  no  reason  for  failing  to  recognise 
the  genuineness  of  the  neurasthenic  syndrome,  char- 
acterised as  it  is  by  headache,  rachialgia,  topoalgia, 
gastro-intestinal  atony,  neuro-muscular  asthenia,  in- 
somnia, and  mental  depression.  The  occurrence  of  any 
one  of  them  in  a  case  of  tic  is  of  no  special  significance  ; 
for  the  diagnosis  of  neurasthenia  rests  on  their  com- 
bination, and  it  is  precisely  this  combination  that  is 
so  exceptional  in  tic. 

From  time  to  time  the  co-existence  or  alternation  of 
tics  and  headache  has  been  remarked,  but  the  headache 
bears  a  much  closer  resemblance  to  migraine  than  to 
the  headache  en  casque  of  neurasthenia. 

Whatever  be  the  variety  of  tic,  the  remarks  we  have 
made,  based  as  they  are  on  clinical  observation,  are 
applicable  to  it.  In  particular,  they  have  a  direct 
bearing  on  Cruchet's  psycho-mental  tic.  To  quote  that 
author  again : 


OTHER  PATHOLOGICAL   CONDITIONS    251 

Hysteria  and  neurasthenia  are  two  diseases  which  we  meet  at  every 
turn  in  our  study  ;  and  if  we  remember  that,  according  to  Raymond, 
fibrillary  chorea  of  Morvan,  paramyoclonus  multiplex  of  Friedreich, 
electric  chorea  of  Henoch-Bergeron,  painless  facial  tic  of  Trousseau, 
and  disease  of  Gilles  de  la  Tourette-Charcot,  are  all  mere  varieties  of 
myoclonus,  which  is  itself  a  product  of  neurasthenia  and  hysteria,  we 
are  forced  to  admit  that  it  is  these  conditions  which  dominate  our 
conception  of  psycho-mental  convulsive  tic. 

Thus  it  comes  to  pass  that  tic  is  lost  in  a  crowd 
of  widely  differing  convulsive  phenomena,  and  is 
threatened  with  the  permanent  loss  of  its  distinctive 
characters,  while  hysteria  itself  is  like  to  become  a 
perfect  Proteus  once  more.  Neurasthenia  too  is  again 
to  sink  to  the  level  of  a  receptacle  for  all  manner  of 
ill  differentiated  conditions. 

"We,  on  the  contrary,  feel  it  more  than  ever  incum- 
bent on  us  to  resist  the  tendency  to  class  in  the  same 
section  facts  which  clinical  observation  distinguishes, 
otherwise  hysteria  and  neurasthenia  will  soon  signify 
nothing  at  all.  If  tic  is  to  be  considered  one  of  the 
polymorphic  manifestations  of  these  diseases,  we  shall 
be  transported  back  fifty  years,  to  the  time  of  the 
famous  "  chaos  of  neuroses,"  out  of  which,  in  some  ways 
at  least,  Charcot  finally  produced  order. 

TIC    AND    EPILEPSY 

The  co-existence  of  epilepsy  and  tic  has  been  noted 
sufficiently  often  to  open  the  question  of  their  possible 
relationship.  Of  course  the  mental  state  of  epileptics 
is  such  as  to  favour  the  development  of  tics.  Usually, 
however,  the  convulsive  phenomena  supposed  to  be  of 
the  nature  of  tic  merit  some  other  description. 

In  the  first  place,  they  may  be  Jacksonian  in  type,  and 
under  these  circumstances  confusion  is  scarcely  possible. 
It  is  not  without  interest  to  compare  the  gestures  and 
stratagems  of  defence  which  sufferers  from  tic  devise, 


252          TICS  AND   THEIR    TREATMENT 

with  the  procedures  adopted  by  some  Jacksonian  patients, 
such  as  compression  of  the  arm  or  wrist  by  the  fingers, 
or  by  string  or  more  elaborate  apparatus.  There  might 
conceivably  be  some  hesitation  in  making  a  diagnosis 
if  it  depended  on  these  arrangements,  but  the  mere 
observation  of  one  actual  attack  will  dispel  all  difficulties. 

We  may  mention  the  convulsive  seizures  of  idiopathic 
epilepsy  only  to  dismiss  them.  Loss  of  consciousness 
is  an  unfailing  criterion. 

It  is  more  especially  the  association  of  epilepsy  with 
the  ill-defined  group  of  myoclonus  that  we  propose 
to  discuss. 

According  to  Maurice  Dide,1  myoclonus,  which  he 
calls  motor  petit  mal,  occurs  in  five  per  cent,  of  cases 
of  epilepsy.  Attention  has  also  been  directed  to  this 
question  by  Mannini8: 

After  an  attack  of  epilepsy  the  convulsive  twitches  are  at  a  minimum, 
but  during  the  next  few  days  the  myoclonus,  or  rather  the  polyclonus, 
becomes  increasingly  intense  and  varied,  until  it  reaches  a  maximum, 
which  is  crowned  by  a  second  epileptic  fit.  The  spasmodic  contractions 
begin  in  the  face  and  invade  the  rest  of  the  musculature  ;  they  recur 
in  the  form  of  seizures  at  diminishing  intervals,  leading  to  the  epileptic 
attack,  when  the  muscles  pass  into  permanent  contraction. 

Sometimes  the  myoclonus  takes  the  shape  of  fibrillary  spasm,  some- 
times the  whole  of  a  muscle  is  involved  ;  the  twitches  may  be  rhythmical 
and  symmetrical,  or  arhythmical  and  asymmetrical,  so  much  so  that  at 
a  given  moment  the  patient  may  present  the  clinical  picture  of  con- 
vulsive facial  tic,  or  paramyoclonus  multiplex,  of  Gilles  de  la  Tourette's 
disease,  or  electric  chorea. 

Mannini's  view  is  that  the  varying  convulsions  known 
as  myoclonus  or  polyclonus  are  akin  to  epilepsy,  and 
are  the  outcome  of  the  same  cortical  lesion,  the  nature 

1  DIDE,  "  La  myoclonie  dans  l'6pilepsie,"  Annales  mtdico-psychol,, 
September — October,  1899. 

8  MANNINI,  "  Policlonia  ed  epilessia,"  Gas.  degli  osped.  e  delle 
din.,  September  30,  1900,  p.  1220. 


OTHER  PATHOLOGICAL   CONDITIONS    253 

of  which  has  not  as  yet  been  fathomed — a  lesion  whose 
expression  is  hyperexcitability  of  the  cells  of  the 
rolandic  area.  Analogous  conclusions  may  be  drawn 
from  a  case  of  epilepsy  and  myoclonus,  with  autopsy, 
reported  by  Rossi  and  Gronzales,1  where  a  general 
ischsemic  degeneration  of  the  central  nervous  system 
was  found,  the  greatest  changes  being  discovered  in  the 
rolandic  zones  of  each  side,  as  well  as  in  the  extremities 
of  the  three  frontal  convolutions.  Schupfer2  has  re- 
corded cases  of  family  myoclonus  with  epileptiform 
attacks. 

We  are  content  to  note  the  facts.  Any  conclusion 
applicable  to  the  tics  is  premature. 

Various  observers  have  drawn  attention  to  the 
development  of  tics  in  persons  formerly  subject  to 
epilepsy.  Malm3  has  described  a  case  of  rotatory  tic 
in  a  man  who  has  been  a  known  epileptic  for  ten  years. 
According  to  Fere,4  epilepsy  may  supervene  in  patients 
who  at  one  time  suffered  from  tic.  As  an  example, 
he  quotes  a  case  of  tic  localised  in  the  left  ear  and 
dating  from  infancy  ;  the  patient  had  reached  his  thirty- 
fifth  year  when  the  recrudescence  of  the  tic  ushered 
in  the  first  attack  of  epilepsy,  which  consisted  of 
elevatory  movements  of  the  left  ear  and  convulsions 
of  the  left  half  of  the  face,  passing  thence  to  the  right 
arm  and  the  left  leg,  and  becoming  generalised.  The 
fact  that  the  twitches  of  the  left  ear  could  not  be 
imitated  voluntarily  suggested  that  the  original  "  tic  " 
may  have  been  the  result  of  some  minute  cortical 
irritation,  the  increase  of  which  became  eventually  the 
determining  cause  of  a  Jacksonian  attack. 

Another  case  due  to   the   same   author  concerns  a 

1  Rossi  AND  GONZALES,  Annali  di  nevrologia,  1900,  fasc.  4. 

2  SCHUPFER,  "Sulle  mioclonie,"  II policlinico,  1901,  vol.  viii.  p.  i. 

3  MALM,  "  Tic  rotatoire,"  Allg.  med.  Centralzeit.,  1899,  No.  64. 

4  F6r6,  "L'epilepsie  et  les  tics,"  Journ.  de  neurologic,  1900,  p.  309. 


254          TICS  AND   THEIR   TREATMENT 

woman  of  fifty-four  years,  subject  from  her  youth  to 
fixed  ideas. 

For  the  last  four  years  she  has  had  seizures  which  may  be  attributed 
to  her  idea  that  she  must  see  the  whole  of  the  objects  on  her  left.  Under 
the  impulse  of  this  idea,  she  turns  her  eyes  upwards  and  to  the  left, 
rotates  her  head  in  the  same  direction,  and  her  body  too,  if  she  happens 
to  be  on  her  feet.  The  performance  is  gone  through  fifteen  or  twenty 
times  a  day. 

In  addition,  she  suffers  from  epileptiform  attacks,  which  commence 
by  this  deviation  of  head  and  eyes  to  the  left,  and  spread  to  the  arms 
and  to  the  left  leg,  leading  to  loss  of  consciousness  as  they  become 
generalised.  The  patient  finally  succumbed  to  an  apoplectic  stroke 
followed  by  left  hemiplegia. 

In  this  instance  the  connection  between  the  fixed 
idea  and  the  patient's  gesture  favours  the  diagnosis 
of  tic,  but  the  subsequent  history  of  the  case  makes 
one  consider  it  with  reserve.  All  such  cases  ought 
to  be  followed  up  carefully,  and  we  may  modify  Fern's 
conclusions  somewhat  to  declare  that  the  appearance 
of  a  convulsive  movement  in  an  adult,  or  the  aggravation 
of  a  similar  movement  of  ancient  date,  should  lead  one 
to  suspect  epilepsy  and  to  look  for  signs  of  it :  "  The 
patient  runs  more  chance  than  risk  in  being  treated 
as  an  epileptic." 

"We  have  had  the  opportunity  of  observing,  in  one 
of  our  mental  torticollis  cases,  a  condition  not  unlike 
what  is  known  as  absence  epileptique.  The  term  "  in- 
cantation "  was  applied  by  the  parent  to  his  daughter's 
habit. 

On  two  occasions  we  noticed  the  patient's  eyes  turn  upward  and 
remain  fixed  for  a  moment  or  two,  while  her  expression  changed  to 
one  of  tranquillity  and  unconcern — a  sign  of  distraction,  not  of  ecstasy. 
She  merely  appeared  to  be  thinking  of  something  other  than  the  im- 
mediate topic  of  conversation,  and  after  two  or  three  seconds  resumed  her 
ordinary  ways. 

These  brief  "  absences "  are  trifling  enough,  of  course,  but  their 
painstaking  study  is  of  inestimable  aid  in  the  matter  of  diagnosis.  They 


OTHER  PATHOLOGICAL   CONDITIONS   255 

began  at  the  age  of  seven  or  eight,  and  at  first  occurred  as  often  as 
sixty  times  in  a  day.  What  the  patient  did  was  to  raise  her  head, 
and  turn  up  the  whites  of  her  eyes ;  in  a  second  or  two  her  countenance 
had  resumed  its  ordinary  expression.  From  their  onset,  the  "  incanta- 
tions"—to  use  her  father's  term — gradually  increased  in  frequency  and 
length,  and  attained  a  sort  of  maximum  when  she  was  eleven  years  old, 
slowly  diminishing  thereafter  till  at  present  they  have  become  rather 
exceptional.  They  proved  to  be  a  source  of  great  tribulation  to  L.,  seeing 
that  she  was  exposed  to  the  practical  jokes  of  her  companions,  who  used 
to  seize  the  occasion  to  relieve  her  of  any  books  or  toys  she  had  in  her 
hand. 

During  the  "absence"  there  is  no  change  of  colour,  nor  has  there 
ever  been  any  vertigo  or  sense  of  rotation.  She  has  never  actually 
fallen,  though  she  has  allowed  things  to  drop  out  of  her  hands.  Once 
it  is  over,  she  is  aware  of  it,  but  her  memory  of  what  has  just 
taken  place  is  very  vague,  though  she  usually  can  tell  what  preceded 
it.  She  can  be  aroused  from  the  "  incantation,"  to  sink  back  into  it  an 
instant  later,  as  though  she  had  not  dreamed  enough.  Sometimes  a  series  of 
"  incantations  "  occurs,  one  following  on  the  heels  of  another.  Occasion- 
ally she  utters  such  words  as  "  yes,  yes  ! "  or  "  no,  no  ! "  in  an  impatient 
tone  of  voice,  and  plucks  at  her  hair  or  clothes,  or  toys  with  the  hand- 
kerchief which  is  never  out  of  her  hands. 

Call  these  phenomena  "  epileptic  absences  "  if  you 
like,  but  after  the  reverie  is  over,  L.  knows  quite 
well  that  she  has  had  it;  besides,  prolonged  bromide 
treatment  has  been  totally  inefficacious. 

One  of  us  has  come  across  a  somewhat  similar 
condition  in  a  ten-year-old  girl: 

Fifty  times  a  day  she  interrupts  her  work  or  her  play  to  retract  her 
head  and  roll  her  eyes  upward.  The  duration  of  the  attack  is  not 
longer  than  ten  seconds,  and  there  is  no  cyanosis  or  distress  of  any  kind. 
The  application  of  tactile  or  painful  stimuli  at  these  times  makes  her  shut 
her  eyes  and  withdraw  her  head  or  her  limbs,  and  she  can  tell  afterwards 
what  was  done.  She  knows  that  she  has  had  a  "  sensation,"  and  remembers 
any  noise  that  occurred  while  she  was  in  that  state. 

Otherwise,  there  is  little  to  note.  For  one  month  she  presented  very 
mild  convulsive  movements  in  the  left  arm  and  leg,  but  no  trace  remains 
of  them  to-day.  Treatment  with  bromides  has  failed  to  effect  any 
modification. 

Examples   of  the   same  nature,   but   said  to   be  of 


2$6          TICS  AND    THEIR   TREATMENT 

hysterical    origin,    have    been    recently   published    by 
Luzenberger : l 

A  young  girl,  twelve  years  of  age,  has  brief  attacks  in  which  she  loses 
consciousness,  and  turns  her  head  to  the  right,  while  the  angle  of  the 
mouth  is  drawn  to  the  left.  This  sort  of  attack  recurs  forty  or  fifty 
times  a  day,  and  has  been  going  on  for  three  or  four  years. 

The  reporter  thinks  the  case  a  difficult  one  to 
diagnose,  though  the  trifling  nature  of  the  symptoms, 
and  their  evolution,  do  not  suggest  epilepsy.  One  may 
question,  however,  whether  they  indicate  hysteria. 

Our  sole  object  in  referring  to  these  cases  has  been 
to  note  the  co-existence  of  these  u  absences"  with  motor 
phenomena  closely  allied  to  the  tics,  if  not  with  tics 
themselves.  We  cannot  be  satisfied  with  finding  a 
common  bond  for  all  such  conditions  in  mental  de- 
generation, but  it  is  perhaps  premature  to  seek  to 
interpret  the  facts. 


TICS— INSANITY— IDIOCY 

Insanity  in  any  of  its  forms  may  be  accompanied  by 
clonic  or  tonic  convulsive  movements — movements  that 
may  be  of  the  nature  of  tics  or  spasms  or  stereotyped  acts, 
or  that  may  belong  to  conditions  which  we  distinguish 
by  the  names  of  myoclonus,  polyclonus,  myotonia, 
catatonia,  etc.  It  is  highly  probable  that  many  instances 
have  been  described  as  spasms  which,  according  to  our 
nomenclature,  must  be  considered  tics.  Brodie,  to  take 
an  example,  quotes  a  case  where  a  "  spasm "  of  the 
spinal  accessory  was  replaced  by  a  mental  affection. 
Alternation  of  hallucinatory  mental  confusion  with 
"  spasm "  of  the  neck  muscles  has  been  observed  by 
Oppenheim,  as  well  as  a  case  where  the  "  spasm " 

1  LUZENBERGER,   '"Absences'  psichiche   in  isterici,"   Riv.  speri- 
ment.  difren.,  1900,  p.  822. 


OTHER  PATHOLOGICAL   CONDITIONS   257 

originated  in  the  course  of  an  attack  of  alcoholic  mania. 
In  another,  due  to  Gowers,  "  spasm "  of  the  muscles 
of  the  neck  was  preceded,  at  a  ten  years'  interval,  by 
an  attack  of  melancholia. 

Most  of  the  cases  of  this  nature  would  be  held  to-day 
to  be  instances  of  mental  torticollis. 

That  tics  and  mental  disease  accompany  each  other 
is  notorious,  but  a  discussion  of  the  question  would 
carry  us  beyond  our  limits.  We  must  say  a  word, 
however,  on  the  tics  of  idiots. 

The  study  of  tic  as  it  occurs  in  idiots,  imbeciles, 
and  arrierfa.  has  engrossed  the  attention  of  alienists 
since  the  days  of  Pinel  and  Esquirol.  Cruchet  says 
the  mental  state  of  the  idiot  and  the  imbecile  is  so 
characteristic  that  the  diagnosis  of  convulsive  tic  in 
such  cases  is  never  attended  with  any  difficulty.  Yet 
the  task  is  sometimes  sufficiently  delicate,  for  we 
maintain  that  upon  our  insight  into  the  subject's  mental 
condition  depends  our  ability  to  analyse  his  tics. 

Considerable  light  has  been  thrown  on  the  question 
by  the  important  information  amassed  by  Bourneville, 
as  well  as  by  the  fine  psychological  studies  of  Sollier 
and  the  meritorious  thesis  of  Noir,  from  which  we 
shall  borrow  largely  in  this  place. 

In  the  first  instance,  we  meet  with  tics  in  every  way 
comparable  to  those  we  have  already  described,  and 
we  may  give  one  or  two  examples. 

R.  accidentally  wounded  his  left  eye  at  the  age  of  eleven,  and  contracted 
a  tic  which  consists  in  spasmodic  blinking  of  the  eyelids,  though  no 
sign  of  ocular  lesion  is  left.  A  diminution  in  its  intensity  has  been  taking 
place,  which  has  culminated  recently  in  its  spontaneous  disappearance. 

N.  had  an  attack  of  ciliary  blepharitis  and  keratitis  which  left 
an  opaque  patch  on  the  upper  and  inner  part  of  his  left  cornea,  and  he 
has  blinked  ever  since.  Yet  there  is  no  local  irritation  to  justify  the 
continuance  of  the  movements. 

The  tics  are  occasionally  as  numerous  and  violent 

17 


258          TICS  AND    THEIR    TREATMENT 

as   in   Gilles   de  la  Tourette's  disease,  and  are  accom- 
panied with  cries  and  with  coprolalia. 

L.  is  afflicted  with  abrupt  blinking  of  the  eyelids,  retraction  of  the 
head,  and  elevation  of  the  lip.  Once  the  tic  is  established,  it  persists 
on  an  average  for  from  eight  days  to  a  month,  and  during  this  time  no 
effort  on  his  part  will  check  it.  Sometimes  he  makes  peculiar  growling 
noises  ;  sometimes  he  cannot  prevent  himself  from  stooping  down  as  if 
to  pick  up  stones  ;  sometimes  he  is  unable  to  restrain  himself  from  touch- 
ing everything  within  reach. 

From  the  age  of  five,  C.  exhibited  frequent  blinking  move- 
ments, and  gestures  which  seemed  to  indicate  that  his  clothes  were 
uncomfortable.  No  attempt  at  modification  was  attended  with  success. 
The  tics  steadily  increased,  till  he  found  himself  uttering  cries  and  letting 
obscene  words  escape  his  lips.  For  a  long  time  they  remained  in  abeyance, 
then  reappeared  in  his  face  and  trunk,  in  the  form  of  salutation  movements. 
His  propensity  for  clastomania,  pyromania,  and  kleptomania  necessitates 
his  being  kept  under  strict  supervision,  and  though  he  is  intelligent  and 
has  a  good  memory,  he  is  also  lazy  and  inattentive. 

Other  tics  of  still  greater  complexity  and  peculiarity 
are  met  with  among  those  whose  psychical  imperfections 
are  very  pronounced.  Some  "  co-ordinated  tics "  are 
remarkable  for  their  intricacy ;  they  consist  of  a  series 
of  movements  which  mimic  some  act  of  everyday  life. 
In  this  group  may  be  specified  various  rhythmical 
movements,  such  as  those  of  balancing,  head  rotation, 
and  striking  or  beating  oneself — the  krouomania  of 
Roubinowitch ;  they  may  be  compared  to  the  mother's 
rocking  of  her  infant,  inasmuch  as  they  have  a  soothing 
effect  on  their  subject,  however  brutal  the  movement 
itself  sometimes  may  be. 

In  most  cases  the  patient  is  seated  and  rocks  himself  to  and  fro  in  an 
antero-posterior  direction.  Or  it  may  be  the  head  only  that  is  rhythmi- 
cally moved  from  side  to  side,  and  the  performance  may  go  on  indefinitely. 
A  mere  touch  or  a  word,  on  the  other  hand,  is  commonly  sufficient  to 
interrupt  its  sequence. 

There  remains  a  final  class  of  co-ordinated  tics,  which 


OTHER  PATHOLOGICAL   CONDITIONS    259 

Noir  distinguishes  by  the  epithet  "  large,"  tics  which 
are  confined  to  idiots  of  good  physical  development. 
They  consist  of  a  movement  or  series  of  movements  of 
considerable  amplitude,  and  constitute  the  predominant 
clinical  feature  of  the  patient's  idiocy.  Here  we  find 
subjects  who  jump,  or  climb,  or  turn  round  and  round  ; 
in  other  cases  they  are  reduced  to  the  level  of  mere 
automata,  and  go  through  a  long  series  of  actions  in 
a  mechanical  way. 

Their  memory  for  recent  occurrences  is  very  poor,  but  in  their  minds 
are  stowed  away  vague  souvenirs  of  events  long  past,  which  they  translate 
into  action,  and  which  they  are  incapable  of  modifying,  even  as  they 
are  unable  to  add  to  their  mental  store  or  to  alter  their  mental  routine. 

A  classic  instance   of  this   variety   of  tic   is  Ros.. 
long  known  at  Bicetre  as  "  the  waltzer." 


CHAPTER    XV 

THE   DISTINCTIVE   FEATURES    OF   TIC 

WE  are  scarcely  inclined  to  believe  in  the  possibility 
of  condensing  into  an  adequately  concise  and 
adequately  precise  formula  our  conception  of  tic,  or 
at  least  all  the  notions  which  contribute  to  it.  Because 
most  authors  feel  it  incumbent  on  them  to  fall  in  with 
this  nosographical  custom,  definitions  have  been  pro- 
posed whose  brevity  only  serves  to  confuse  the  issue. 
Opinion  on  the  interpretation  of  certain  words  which 
concern  our  subject  is  far  from  being  unanimous,  and, 
as  we  remarked  at  the  outset,  accuracy  in  our  ter- 
minology is  urgently  called  for.  This  has  been  our 
reason  for  preceding  our  definitions  by  the  results  of 
clinical  observation  and  pathogenic  analysis. 

Our  idea  of  tic,  however,  may  be  couched  in  the 
following  terms : 

A  tic  is  a  co-ordinated  purposive  act,  provoked  in  the 
firsf  instance  by  some  external  cause  or  by  an  idea ;  re- 
petition leads  to  its  becoming  habitual,  and  finally  to 
its  involuntary  reproduction  without  cause  and  for  no 
purpose,  at  the  same  time  as  its  form,  intensity,  and 
frequency  are  exaggerated;  it  thus  assumes  the  characters 
of  a  convulsive  movement,  inopportune  and  excessive;  its 
execution  is  often  preceded  by  an  irresistible  impulse,  its 
suppression  associated  with  malaise.  The  effect  of  distrac- 
tion or  of  volitional  effort  is  to  diminish  its  activity ;  in 

060 


THE  DISTINCTIVE  FEATURES   OF   TIC    261 

sleep  it  disappears.     It  occurs  in  predisposed  individuals, 
who  usually  show  other  indications  of  mental  instability.1 

We  are  in  a  position,  now,  to  elaborate  the  details 
of  this  definition.  Tic  is  a  psycho-motor  affection,  and 
there  are  two  inseparable  elements  in  its  constitution, 
a  mental  defect  and  a  motor  defect. 

The  prevailingjnental  defect  is  impairment  of  voli- 
tion, which  takes  the  form  either  of  debility  or  of 
versatility  of  the  will.  This  being  characteristic  of  the 
mind  of  the  child,  its  continuance  in  spite  of  years 
argues  a  partial  arrest  of  psychical  development. 
Hence  the  epithet  infantile  may  be  employed  to  qualify 
the  patient's  mental  state. 

Other  psychical  troubles,  which  similarly  are  anomalies 
of  volition,  may  be  superadded,  in  particular  impulsions 
and  obsessions. 

Speaking  generally,  a  certain  degree  of  mental  in- 
stability is  a  distinguishing  feature  of  the  patient  with 
tic. 

The  defect  of  motility  consists  at  first  in  the  provoca- 
tion of  a  motor  reaction  by  some  external  cause,  or  by 
an  idea. 

In  the  former  case,  the  reaction  is  the  cortical  re- 
sponse to  a  peripheral  stimulus,  and  its  logical  execu- 
tion becomes  by  dint  of  repetition  habitual  and  , 
automatic.  With  the  disappearance  of  the  stimulus  it 
continues  to  manifest  itself,  without  cause  and  for  no 
purpose,  in  which  circumstances  the  feebleness  of  the 
inhibitory  power  of  the  will  is  revealed. 

In  the  latter  case,  the  motor  reaction  is  called  into 
being  under  the  influence  of  an  idea,  normal  or  patho- 
logical, which  eventually  ceases  to  operate,  and  by 
virtue  of  the  same  pathogenic  mechanism  the  act  re- 
mains, inopportune  and  exaggerated. 

The   objective   manifestation   of  tic  is   a  clonic   or 

1  MEIGE,  Les  tics,  July,  1905  (Masson). 


262         TICS  AND   THEIR    TREATMENT 

tonic  convulsive  movement,  an  anomaly  by  excess  of 
muscular  contraction. 

In  the  clonic  variety  there  are  undue  rapidity  and 
increased  frequency  of  the  movements. 

In  the  tonic  variety,  the  duration  of  the  contraction 
is  prolonged. 

The  intensity  of  the  movements,  likewise,  is  ab- 
normal in  degree. 

In  spite  of  these  disfigurations,  so  to  speak,  of  the 
original  movement,  it  is  practically  always  possible  to 
detect  in  them  co-ordination  and  purpose,  the  cause  and 
the  significance  of  which  ought  to  become  the  object 
of  our  search. 

The  motor  disorder  can  never  be  reduced  to  mere 
fibrillation,  nor  indeed  to  fascicular  contraction  unless 
in  some  one  muscle  different  bundles  have  different 
physiological  attributes.  It  is  usual  for  several  muscles 
to  be  concerned,  and  their  anatomical  nerve  supply 
may  be  from  separate  sources. 

Like  ordinary  functional  motor  acts,  tics  are  dis- 
tinguished by  co-ordination  of  muscular  contraction  and 
repetition ;  they  are  preceded  by  a  desire  for  their 
execution,  and  succeeded  by  a  feeling  of  satisfaction. 

These  features,  however,  are  carried  to  excess. 

In  addition,  the  functional  act  is  inapposite,  some- 
times even  harmful ;  it  may  be  described  as  a  parasite 
function. 

The  muscular  contractions  follow  each  other  at 
irregular  intervals  ;  they  come  in  attacks,  which,  it  is 
true,  are  highly  variable  in  frequency,  duration,  and 
degree. 

Volition  and  attention  exercise  a  restraining  in- 
fluence on  the  motor  phenomena,  but  repression  is 
accompanied  by  malaise,  sometimes  by  actual  anguish. 

Distraction  suspends  the  activity  of  tic ;  physical 
fatigue  and  emotion  are  calculated  to  arouse  it. 


THE   DISTINCTIVE  FEATURES   OF  TIC   263 

Tics  always  disappear  in  sleep. 

They  are  unaccompanied  by  any  alteration  in  sensa- 
tion, in  the  reflexes,  or  in  the  trophic  functions. 
They  are  not  associated  with  pain. 

In  this  general  way  we  have  indicated  the  distinctive 
features  of  tic,  and  we  may  take  the  opportunity  to 
remind  ourselves  of  their  extreme  variability. 

In  discussing  the  question  of  diagnosis,  we  shall 
have  occasion  to  emphasise  the  importance  of  fruste, 
atypical,  and  transitional  cases,  not  because  we  think 
they  can  be  systematised  as  yet,  but  because  they  may 
be  capable  of  new  pathogenic  interpretations  which  we 
cannot  afford  a  priori  to  set  aside. 

We  venture  to  believe  that  tic  has  a  clinical  in- 
dividuality of  its  own  which  we  have  tried  to  portray, 
and  we  go  so  far  as  to  say  that  an  appreciation  of  the 
points  we  have  touched  on  will  prove  of  service  in 
matters  of  diagnosis. 


CHAPTER   XVI 

DIAGNOSIS 

TICS  AND  STEREOTYPED  ACTS 

WE  have  already,  on  more  than  one  occasion, 
drawn  attention  to  the  phenomena  known  as 
stereotyped  acts,  demonstrating  their  intimate  kinship 
with  the  tics  and  the  frequent  difficulty  of  establishing 
a  differential  diagnosis.  To  ensure  precision  of  ideas 
and  of  terminology,  we  must  restrict  the  expression  to 
motor  disturbances  in  which  the  characters  of  the 
muscular  contraction  are  identical  with  those  of  normal 
acts.  On  this  view  many  motor  reactions  are  really 
classifiable  as  stereotyped  acts,  and  among  them  are 
those  denominated  by  Letulle  "  habit  tics." 

Stereotyped  acts  occur  in  normal  individuals,  and  it 
may  fairly  be  said  there  is  no  one  but  has  his  habitual 
gesture,  his  movement  of  predilection.  As  a  matter 
of  fact,  a  certain  number  of  what  Letulle  calls  co- 
ordinated tics  belong  to  the  group  under  consideration ; 
others,  no  doubt,  are  genuine  tics,  and  between  the  two 
may  be  found  innumerable  intermediate  varieties. 

From  the  diagnostic  standpoint  the  stereotyped  acts 
that  occur  in  the  course  of  mental  disease,  of  which  a 
conscientious  study  has  recently  been  made  by  Cahen,1 
are  highly  instructive.  He  defines  them  as  non- 

1  CAHEN,  "Contribution  £  l'6tude  des  st6r6otypies,"  Archives  de 
ntvrologic,  1901,  p.  474- 

364 


DIAGNOSIS  265 

convulsive,  co-ordinated  attitudes  or  movements,  re- 
sembling intentional  or  professional  acts,  repeated  at 
frequent  intervals  and  always  in  the  same  fashion,  till 
their  conscious  and  voluntary  performance  is  replaced 
by  a  degree  of  subconscious  automatism.  In  the  case 
of  the  insane  they  are  secondary  to  some  delusion,  and 
persist  though  the  latter  may  disappear.  Hence  the 
patient  may  be  incapable  of  explaining  his  movements 
and  attitudes,  however  much  he  may  persevere  in  their 
automatic  execution — an  evolutionary  process  akin  to 
that  of  the  tics. 

A  typical  instance  may  be  quoted  from  Seglas : 

B.  passed  under  observation  in  1891,  suffering  from  delusions  of 
persecution,  and  not  long  afterwards  it  was  noticed  that  from  time  to 
time  he  used  to  come  to  a  halt  in  the  courtyard,  gaze  at  the  sun,  and 
rotate  his  hands  round  an  imaginary  axis.  The  reply  he  vouchsafed 
to  interrogation  on  this  point  was  that  he  was  effecting  the  sun's  re- 
volution. At  present,  however,  he  has  sunk  into  a  state  of  dementia, 
and  while  the  gesture  continues  he  is  unable  to  furnish  any  explanation 
of  it. 

Of  course  it  is  inadmissible  to  apply  the  term  to 
co-ordinated  acts  that  are  neither  conscious  nor  volun- 
tary, such  as  the  teeth  grinding  of  the  general  paralytic, 
or  the  body  oscillation  of  the  idiot.  Similarly  one 
must  differentiate  them  from  impulsive  seizures,  abrupt 
irresistible  motor  explosions  neither  frequent  nor 
prolonged. 

A  distinction  has  been  drawn  between  akinetic  (at- 
titude) stereotyped  acts  and  parakinetic  (movement) 
stereotyped  acts.  As  instances  of  the  former  we  may 
give  the  following : 

A  woman  reclines  continuously  in  bed  because  she  believes  she  has 
an  infernal  machine  in  her  abdomen. 

Another  patient  sits  on  the  ground  all  day  long,  buttoning  and 
unbuttoning  his  clothes. 

An  old  gymnast  maintains  while  he  stands  a  professional  attitude  in 


266         TICS  AND   THEIR    TREATMENT 

which  his  head  is  raised,  his  right  fist  closed  on  his  hip,  his  right  leg  crossed 
in  front  of  the  left,  and  his  right  foot  elevated  vertically. 


Conditions  such  as  these  present  the  most  intimate 
analogies  to  our  attitude  tics,  though  in  the  case  of  the 
latter  there  is  always  a  more  or  less  pronounced  ex- 
aggeration of  muscular  contraction,  a  certain  degree  of 
tonic  convulsion. 

Parakinetic  stereotyped  acts  are  of  common  occur- 
rence, and  embrace  every  variety  of  movement  or 
gesture. 

A  former  acrobat  leaps  staircases,  climbs  railings,  exercises  his  arms 
rhythmically  and  regularly,  etc. 

A  patient  promenades  untiringly  in  the  same  corner  and  at  the  same 
pace. 

An  old  engraver,  now  a  dement,  passes  the  day  in  reproducing  in 
a  more  or  less  modified  form  certain  actions  associated  with  his  former 
profession. 

Alike  in  tics  and  in  stereotyped  acts,  a  time  comes 
when  the  motor  habit  establishes  itself,  for  no  apparent 
reason  or  purpose ;  hence  the  co-existence  of  the  two 
classes  in  chronic  delusional  insanity,  in  dementia 
precox,  in  catatonic  states,  in  systematised  mental 
disease  of  other  forms,  and  in  general  paralysis. 

Stereotyped  acts  may  be  the  embodiment  of  ideas  of 
persecution  and  of  grandeur,  or  the  outcome  of  mystical, 
hypochondriacal,  and  other  states.  A  patient  with 
delusions  of  persecution  writhes  because  he  is  being 
"  electrified."  A  hypochondriac  rests  motionless  because 
he  believes  himself  made  of  glass.  A  mystic  maintains 
an  attitude  of  genuflexion  for  hours  at  a  time. 

Obsessions  also  play  a  part  in  the  genesis  of  the  acts 
we  have  under  consideration,  but  of  all  delusional  ideas 
those  of  defence  are  the  most  fertile  in  this  respect. 

A  patient  under  the  care  of  A.  Marie  used  to  carry  a 


DIAGNOSIS  267 

fragment  of  glass  between  Ms  teeth  and  other  pieces 
beneath  the  soles  of  his  feet,  the  idea  being  that  they 
formed  insulating  cushions  whereby  to  protect  himself 
from  the  electricity  of  his  enemies. 

The  suggestion  was  thrown  out  by  Bresler  that  the 
movements  of  tic  are  often  of  a  defensive  character — 
that  the  disease,  in  fact,  is  a  sort  of  "  defence  neurosis  " 
linked  to  hyperexcitability  of  psychomotor  centres. 
This  theory  is  not  unlike  the  view  of  hysteria  taken 
by  Brener  and  Freud,  and  as  the  movements  themselves 
are  usually  of  the  nature  of  mimicry,  Bresler  has  pro- 
posed the  term  mimische  Krampfneurose. 

In  some  cases  of  mental  torticollis,  the  attitude 
assumed  may  be  considered  as  a  stereotyped  act.  Martin 
has  recorded  an  example  of  torticollis  in  relation  to 
melancholia.  Another  of  his  patients  suffered  from 
rotation  of  the  head  to  the  left,  a  position  which  could 
easily  be  rectified  by  asking  the  man  to  make  the  sign 
of  the  cross.  The  moment  he  put  his  finger  on  his 
forehead  the  displacement  of  the  head  was  corrected. 
If,  however,  he  were  requested  to  look  straight  in  front 
of  him,  he  remained  incapable  of  altering  the  vicious 
attitude,  the  reason  he  advanced  being  that  he  could  no 
longer  see  the  sun. 

One  cannot  but  be  struck  with  the  remarkable 
analogies  to  the  cases  given  by  Cohen.  And  it  is 
worth  remembering  further,  that  sometimes  mental 
torticollis  degenerates  into  actual  dementia. 

TICS  AND  SPASMS 

Nothing  is  more  arduous,  at  first  sight,  than  the 
differentiation  of  a  tic  from  a  spasm,  the  similarity  of 
their  external  forms  being  a  fertile  source  of  confusion. 
Yet  the  establishment  of  a  correct  diagnosis  is  of  prime 
importance,  since  in  their  case  prognosis  and  treatment 
alike  are  diametrically  opposed. 


268         TICS  AND    THEIR    TREATMENT 

Tic  is  a  psychical  affection  capable  of  being  cured, 
if  one  can  will  to  cure  it :  at  the  worst  we  may 
fail,  but  there  is  no  idea  that  it  is  indicative  of  a 
grave  organic  lesion  prejudicial  to  life.  A  spasm,  on 
the  contrary,  though  it  appear  in  almost  identical  garb, 
is  excited  by  a  material  lesion  on  which  depends  the 
degree  of  its  gravity.  The  focus  of  disease  may  dis- 
appear, no  doubt,  but  it  is  only  too  likely  to  persist 
and  to  occasion  other  disorders.  Hence  the  desirability 
of  making  sure  of  one's  diagnosis — a  proceeding  not 
necessarily  of  insuperable  difficulty.  If  we  apply  the 
principles  of  diagnosis  enunciated  by  Brissaud,  to  which 
our  attention  has  already  been  directed,  we  shall  not 
find  the  task  beyond  our  powers. 

Let  us  take  a  concrete  instance. 

Here  is  a  cabman,  forty-nine  years  of  age,  the  left  half  of  whose 
face  is  the  seat  of  convulsive  twitches.  These  commenced  eighteen 
months  ago  by  brief  insignificant  contractions  of  the  left  orbicularis 
palpebrarum,  which  have  gradually  spread  to  the  whole  of  the  muscular 
domain  supplied  by  the  left  facial  nerve.  Their  momentariness  and 
rapidity,  their  apparent  independence  of  extraneous  stimuli,  their  in- 
difference to  treatment  and  resemblance  to  the  twitches  produced  by 
electrical  excitation,  their  occurrence  in  sleep,  the  fact  of  voluntary  effort, 
of  attention  or  distraction,  serving  so  little  to  modify  their  range  and 
intensity — all  make  clear  the  spasmodic  nature  of  the  condition. 

The  motor  manifestation  is  the  consequence  of  irritation  at  some 
point  on  a  bulbo-spinal  reflex  arc  ;  its  abruptness  and  instantaneousness 
negative  the  possibility  of  recognising  in  it  any  sign  of  functional  systema- 
tisation.  It  is  not  a  co-ordinated  act  of  a  purposive  nature,  but  a  simple, 
unvarying,  constant  motor  reaction  to  a  particular  stimulus.  That  its 
intensity  should  be  in  direct  proportion  to  the  intensity  of  the  latter, 
changing  from  feeble  contractions  to  a  state  of  transient  tetanus,  is 
further  proof  of  its  spasmodic  origin.  When  the  excitation  is  at  its 
maximum,  there  is  sometimes  involvement  of  the  opposite  side  of  the 
face,  by  virtue  of  the  law  of  the  generalisation  of  reflexes. 

It  is  true  there  is  no  association  of  pain  with  his  attacks,  as  in  so- 
called  tic  douloureux,  but  the  spasm  is  heralded  by  a  tingling  sensation 
below  and  to  the  inner  side  of  the  outer  corner  of  the  eye.  This 
sensation,  "  like  an  electric  battery,"  persists  during  the  spasm  and 
disappears  in  the  intervals.  Its  occurrence  suggests  that  the  ascending 


DIAGNOSIS  269 

branch  of  the  infraorbital  nerve,  springing  from  the  trigeminal,  is  affected, 
and  indeed  pressure  over  its  point  of  emergence  evokes  a  certain  amount 
of  pain.  Moreover,  there  is  occasionally  a  flow  of  tears  when  the  spasm 
is  at  its  height.  It  may  be  difficult  to  decide  whether  this  is  the  result 
of  mechanical  compression  of  the  lachrymal  gland  or  an  exaggerated 
secretion  of  tears  under  the  influence  of  stimulation  of  the  lachrymo- 
palpebral  twig  of  the  orbital  nerve.  In  any  case  the  pathogeny  of 
this  facial  spasm  is  entirely  comparable  to  that  of  tic  douloureux  of 
the  face,  and  it  is  quite  within  the  bounds  of  possibility  that  a  minute 
haemorrhage — for  the  patient  is  of  a  very  florid  type — somewhere  oh 
the  centrifugal  path  of  the  trigemino-facial  reflex  arc,  may  be  giving 
rise  to  the  phenomena. 

What  we  wish  to  insist  on,  however,  is  the  dissimilarity  between  this 
facial  spasm  and  tic.  In  the  movements  we  have  been  describing  we 
fail  to  distinguish  any  purposive  element,  any  co-ordination  for  the 
fulfilment  of  a  particular  function  :  they  are  not  imitative  in  character, 
nor  do  they  express  any  sentiment ;  no  impulse  precedes  their  execution, 
no  satisfaction  follows. 

The  patient's  mental  state  presents  no  peculiarities,  as  far  as  we  have 
been  able  to  discover.  There  is  no  volitional  debility  or  instability  ; 
if  he  cannot  control  the  convulsions,  it  is  to  be  remarked  that  he  cannot 
control  them  even  for  a  moment,  whereas  all  sufferers  from  tic  are  capable 
of  inhibiting  it  for  a  longer  or  shorter  period  by  an  effort  of  the  will, 
by  concentrating  their  attention  on  it.1 


The  following  remarks  on  this  case  are  due  to 
Professor  Joffroy  : 

If  the  patient  be  asked  to  open  his  mouth,  the  spasm  of  the  left 
cheek  remains  in  abeyance  as  long  as  it  is  open,  but  the  platysma  of 
the  same  side  then  begins  to  twitch  spasmodically.  Or  if  he  be  requested 
to  shut  his  eyes,  so  long  as  they  continue  closed  the  cheek  is  quiescent  ; 
but,  on  the  other  hand,  both  orbiculares  palpebrarum,  as  well  as  the 
pyramidal  muscles  and  the  adjacent  fibres  of  the  frontalis,  are  seen  to 
contract  irregularly.  There  is  a  sort  of  transference  of  spasm,  and  this 
is  of  peculiar  interest,  inasmuch  as  it  affords  evidence  that  the  lesion 
is  not  so  restricted  as  one  might  suppose. 

The  explanation  no  doubt  is  to  be  sought  in  the  law  of  the  diffusion 
of  reflexes,  confirming  the  diagnosis  of  an  irritative  lesion  at  some  point 
on  the  trigemino-facial  reflex  arc. 

1  MEIGE,  "  Spasme  facial  franc,"  Soc.  de  neitr.  de  Paris,  April  17, 
1902. 


270         TICS  AND    THEIR    TREATMENT 

In  the  differential  diagnosis  of  spasm  assistance 
may  be  obtained  by  a  consideration  of  the  following 
points : 

The  extreme  abruptness  of  the  movement  recalls 
the  contractions  produced  by  electrical  stimulation. 

There  is  no  purposive  or  co-ordinated  feature  in 
the  spasm,  which  is  confined  to  some  nerve  area 
anatomically  limited. 

Volition,  attention,  distraction,  emotion,  all  fail  to 
effect  any  modification  of  the  phenomena. 

No  irresistible  impulse  precedes  their  manifestation, 
nor  is  it  succeeded  by  a  feeling  of  satisfaction.  Some- 
times the  spasm  is  accompanied  by  severe  pain. 

As  a  general  rule  the  patient's  mental  state  does- 
not  present  the  anomalies  met  with  so  frequently  among 
those  who  tic. 

Important  information  may  be  gleaned  from  a 
scrutiny  of  the  condition  during  sleep.  Should  the 
convulsive  movement  persist,  it  may  be  said  with  con- 
fidence to  be  a  spasm  ;  whereas  if  it  completely  disappear, 
it  is  probably  a  tic.  Whether  a  spasm  may  vanish 
in  sleep,  however,  is  another  question,  which  clinical 
observation  has  not  yet  satisfactorily  answered,  and 
if  no  other  indication  of  organic  disease  be  forthcoming, 
the  problem  must  in  the  present  state  of  our  knowledge 
be  left  unsolved. 

A.  Tic  or  Spasm  of  the  Face 

In  cases  where  the  face  is  the  seat  of  the  convulsive 
movements  this  problem  of  diagnosis  becomes  one  of 
the  utmost  nicety.  That  a  distinction  may  be  drawn, 
however,  is  universally  admitted.  Hallion,1  for  instance, 
specifically  separates  clonic  spasms  due  to  structural 

1  HALLION,   "  Convulsions  localises,"  Traite  de  medecine^  vol.  vi. 
p.  897. 


DIAGNOSIS  271 

changes  from  the  "  nervous  movements  "  of  neuroses 
such  as  chorea  or  tic.  Facial  spasm  is  rigorously 
limited  to  the  distribution  of  the  nerve,  and  is  commonly 
the  result  of  some  alteration  in  it  effected  by  causes 
similar  to  those  that  occasion  facial  paralysis. 

Clonic  spasms  of  the  face  are  occasionally  a  sequel 
to  local  traumatism — that  is  to  say,  they  are  the  result 
not  of  direct  but  of  reflex  excitation  of  the  facial  nerve. 
Tic  douloureux  belongs  to  this  class.  Tic  non-douloureux 
also  is  sometimes  merely  a  simple  reflex  spasm. 

One  of  the  most  pregnant  of  Brissaud's  lessons  is 
devoted  to  the  elucidation  of  this  part  of  our  subject, 
and  we  have  already  made  several  quotations  from  it. 
In  many  cases  he  is  forced  to  say,  "  I  decline  to  hazard 
a  diagnosis  when  etiology  is  silent."  We  too  have  been 
face  to  face  with  this  diagnostic  difficulty  on  several 
occasions,  and  it  may  be  instructive  to  give  the  details 
of  one  or  two  cases  where  no  definite  conclusion  could 
be  arrived  at. 

A  man  thirty-seven  years  of  age  had  been  suddenly  seized  with  facial 
paralysis  on  the  left  side  thirteen  years  before,  accompanied  after  an 
interval  of  eight  days  by  bilateral  fronto-temporal  cephalalgia,  nausea, 
vomiting,  and  disturbances  of  vision.  These  attacks  recurred  irregularly 
during  the  next  four  years,  since  when  they  have  ceased,  although  the 
palsy  persists.  Recently  the  patient  woke  up  abruptly  in  the  middle  of 
the  night  to  find  that  the  left  side  of  the  face  was  in  a  state  of  spasmodic 
contraction,  a  condition  which  has  continued  absolutely  without  inter- 
mission. There  is  no  pain  in  relation  to  the  spasm,  merely  a  peculiar 
sensation  at  the  site  of  the  muscular  twitches.  Of  what  nature  are 
they  ? 

If  we  analyse  the  muscular  play  somewhat  more  closely,  we  observe 
that  with  the  exception  of  the  frontalis  all  the  muscles  of  the  left  face, 
including  the  platysma,  contribute.  On  a  background  of  more  or  less 
permanent  contraction  are  outlined  short,  incomplete,  greatly  varying 
twitches,  affecting  one  muscle  after  another,  and  sometimes  only  a  few 
fibres,  in  a  highly  erratic  way.  The  march  of  the  movements  obeys  no 
law,  either  of  space  or  time,  nor  is  there  any  co-ordination  in  their  activity. 
That  the  condition  is  one  of  tic,  therefore,  is  scarcely  conceivable.  No 
purposive  element  is  discoverable  in  the  phenomena,  no  systematisation, 


272         TICS  AND    THEIR    TREATMENT 

no  expression  of  emotional  excess.  All  is  disorder,  confusion  con- 
tradiction. 

We  should,  accordingly,  be  content  to  make  a  diagnosis  of  spasm, 
but  an  examination  of  the  patient's  mental  condition  must  not  be 
neglected,  and  in  this  particular  case  it  is  very  instructive. 

It  appears  that  his  imagination  has  always  been  singularly  fertile, 
amounting  indeed  to  eccentricity.  The  picturesque  description  he 
furnished  of  the  unusual  sensations  in  face  and  neck  lent  support  to  the 
view  that  his  muscular  activity  was  intended,  consciously  or  unconsciously, 
to  free  himself  from  their  insistence,  so  that  his  grimacing  may  have  been 
but  a  gesture  of  defence. 

But  however  much  his  lack  of  psychical  equilibrium  may  favour  the 
relegation  of  his  affection  to  the  category  of  tic,  certain  considerations 
make  one  question  the  validity  of  the  hypothesis. 

In  the  first  place,  it  is  rather  an  uncommon  functional  adaptation 
of  the  facial  muscles  to  utilise  them  in  an  attempt  to  disembarrass  oneself 
of  disagreeable  sensations  ;  and  in  the  second  it  is  no  less  uncommon  for 
the  sufferer  from  tic  to  be  unable  to  restrain  his  muscles  even  moment- 
arily, as  our  patient  appears  to  be.  The  actual  time  of  onset  of  the 
movements  is  significant  enough,  but  of  supreme  importance  is  the  fact 
of  their  supervention  in  an  area  previously  the  seat  of  paralysis.  To 
our  mind  this  is  more  than  a  coincidence  ;  from  the  history  supplied  by 
the  patient  it  is  plain  that  the  paralysis  was  peripheral  and  that  the  lesion 
involved  the  facial  trunk  somewhere  in  its  intracranial  course  after  its 
emergence  from  the  side  of  the  pons.  Thirteen  years  later,  convulsive 
movements  appear  in  the  same  domain.  Taking  all  the  circumstances 
into  consideration,  we  think  the  hypothesis  tenable  that  the  trigeminal 
is  implicated  in  the  pathogeny  of  the  spasm,  although  the  condition  is 
not  strictly  comparable  to  the  classic  tic  douloureux. 

The  exact  nature  of  the  lesion  is  more  difficult  to  determine.  A 
review  of  the  details  of  the  facial  palsy  suggests  its  vascular  origin, 
to  which  theory  the  headache,  nausea,  and  photophobia  of  succeeding 
days  and  months — indicating,  as  they  do,  a  circulatory  disturbance  in  the 
basilar  region — lend  support.  With  the  gradual  restoration  of  vascular 
equilibrium  the  migrainous  attacks  lessened  in  frequency  and  severity, 
though  the  facial  trunk  remained  compressed,  till  the  spasm  appeared, 
no  less  suddenly  than  had  the  paralysis.  It  is  feasible  that  the  former,  too, 
is  the  derivative  of  a  minute  haemorrhage  irritating  either  the  centrifugal 
or  the  centripetal  arm  of  the  facial  reflex  arc,  probably  the  latter,  which 
would  explain  the  parassthesiae. 

The  possibility  of  this  explanation  being  accurate  is  confirmed  by  a 
case  reported  by  Schflltz,  where  facial  spasm  of  ten  years'  duration  was 
shown  at  the  autopsy  to  have  been  caused  by  an  aneurism  of  the  left 
vertebral  artery  impinging  on  the  facial  nerve  in  the  neighbourhood 
of  the  basilar  trunk. 


DIAGNOSIS  273 

The  arguments,  therefore,  which  plead  in  favour  of  the  spasmodic 
nature  of  the  condition  seem  to  us  so  cogent  that  the  hypothesis  of  tic  must 
be  rejected.  We  ought  not  to  forget,  on  the  other  hand,  that  a  spasm, 
of  whatsoever  origin,  may  be  transformed  into  a  tic  by  the  perpetuation 
of  a  morbid  habit. 

Let  us  take  a  second  case,  no  less  instructive  than 
the  preceding. 

Madame  L.  was  sent  to  one  of  us  by  Professor  Pierre  Marie. 
She  had  always  been  nervous,  impressionable,  and  high-spirited,  but  had 
never  suffered  from  fits.  At  the  age  of  eight  years,  during  convalescence 
from  one  of  the  exanthemata,  she  got  a  chill,  and  the  very  next  day 
developed  an  acutely  painful  torticollis,  the  head  resting  on  the  right 
shoulder  and  the  chin  touching  the  left  clavicle.  A  complete  cure  ensued, 
but  from  that  time  a  certain  degree  of  facial  asymmetry  was  remarked. 
At  the  age  of  eight  and  a  half  menstruation  commenced,  and  it  still 
continues,  at  the  age  of  fifty-nine. 

From  youth  she  had  at  intervals  been  stricken  with  pains  in  the  limbs, 
and  with  recurrent  bilious  attacks.  Two  years  ago  the  death  of  her 
husband  was  the  occasion  of  great  mental  strain  and  distress.  Sixteen 
months  ago  she  noticed  a  curious  sensation  in  the  right  eye,  not  painful, 
accompanied  from  time  to  time  by  blinking  of  the  lids.  Very  gradually 
the  convulsive  movements  spread  over  the  whole  of  the  right  face,  and 
for  the  last  month  their  frequency  and  intensity  have  been  such  that  rest 
is  an  impossibility. 

When  she  came  under  observation  what  impressed  the  mind  first 
was  the  remarkable  asymmetry  of  her  figure  :  the  right  side  of  the 
face  was  smaller  than  the  left,  the  right  eye  appeared  to  be  at  a  lower 
level  than  the  other,  while  the  mouth  was  strongly  deviated  to  the 
right  and  the  chin  twisted  in  the  same  direction.  For  a  minute  or 
two  the  facial  contortion  held  sway,  disappearing  only  to  reappear 
quickly. 

Not  solely  to  the  old  torticollis  was  the  facial  asymmetry  attributable, 
but  also  to  the  convulsive  movements  of  the  right  half  of  the  face. 
The  effect  of  these  was  to  close  the  right  eye,  deflect  the  nose  to  the 
same  side,  drag  the  mouth  in  a  similar  fashion,  and  wrinkle  the  skin 
of  the  chin  and  neck.  Hence  was  evolved  a  unilateral  grimace  quite 
unlike  any  ordinary  expression,  resembling  rather  the  facies  in  con- 
tracture  secondary  to  facial  paralysis. 

During  the  next  few  months  there  was  a  gradual  change  from  this 
tonic  to  a  clonic  stage,  in  which  the  movements  were  of  less  frequent 
occurrence,  but  more  rapid.  In  repose  there  was  no  further  indication 

18 


274         TICS  AND    THEIR    TREATMENT 

of  the  old  facial  palsy  than  the  flattening  of  the  facial  lines  on  the 
right.  Under  the  influence  of  any  emotion,  or  any  passing  contrariety, 
or  in  the  course  of  an  animated  conversation,  or  if  circumstances  call 
for  their  repression,  the  spasms  increase  in  number  and  degree,  whereas 
solitude  and  tranquillity  favour  their  subsidence. 

A  recent  development  has  been  the  discovery  of  a  means  of  checking 
the  spasm — viz.  by  compressing  the  larynx  with  the  fingers  of  the 
two  hands.  Madame  L.  admits  the  illogical  nature  of  the  manoeuvre, 
but  extols  its  efficacy.  As  a  matter  of  fact,  it  sometimes  fails  of  its  object. 

How,  then,  is  this  localised  convulsive  movement  to  be  designated  ? 
Is  it  a  tic  or  is  it  a  spasm  ? 

The  march  of  the  disease,  its  painlessness,  the  absence  of  any  reaction 
in  sleep,  the  success  of  the  little  laryngeal  trick,  the  inhibitory  effect 
of  the  will,  the  definite  influence  of  attention,  distraction,  in  short  of 
the  psychical  condition  of  the  moment — all  plead  in  favour  of  its  classifi- 
cation in  the  former  category.  On  the  other  hand,  we  cannot  shut  our 
eyes  to  the  fact  of  the  pre-existence  of  specific  organic  disease,  and, 
moreover,  the  spasm  is  strictly  confined  to  the  anatomical  distribution 
of  the  facial  nerve.  Even  in  periods  of  repose  there  is  a  certain  amount 
of  fibrillation  on  that  side.  On  these  counts  are  we  to  hazard  the 
diagnosis  of  facial  trophoneurosis  ? 

A  subsequent  opportunity  of  examining  the  same  patient  served 
to  confirm  the  diagnosis  of  spasm  secondary  to  facial  dystrophy,  and 
treatment  failed  to  make  any  impression  on  the  condition. 

Our  object  in  giving  these  cases  has  been  to  point 
out  the  difficulties  in  the  way  of  diagnosis,  especially 
where  spasm  is  superadded  to  a  mental  state  that  itself 
predisposes  to  tic.  The  wisest  plan  in  many  instances 
is  to  confine  oneself  to  a  description  of  the  symptoms 
and  to  tabulate  the  arguments  for  and  against  a 
particular  view,  without  perpetrating  the  error  of 
committing  oneself. 

Many  cases  labelled  convulsive  tic  might  be  quoted 
where  the  expression  of  so  definite  an  opinion  ought 
to  have  been  reserved,  as  in  one  reported  by  Mayer l 
under  the  title  of  convulsive  tic  consecutive  to  in- 
fraorbital  neuralgia : 

A  man,  thirty-two  years  of  age,  had  suffered  from  a  severe  infra - 
1  MAYER,  Alienist  and  Neurologist,  July,  1897. 


DIAGNOSIS  275 

orbital  neuralgia  of  some  weeks'  duration,  apparently  attributable  to 
a  chill.  The  pains  recurred  at  intervals  till  their  substitution  five  years 
later  for  slight  spasmodic  twitches  of  the  left  eyelid,  which  gradually 
developed  into  violent  convulsions  of  the  whole  of  the  left  half  of  the 
face.  These  spasms  were  preceded  by  a  sensation  of  numbness  in  the 
left  ear,  while  during  repose  no  modification  of  facial  expression  was  to 
be  remarked. 

Further,  there  was  a  history  of  exactly  similar  neuralgia  and  spasm 
in  the  mother  of  the  patient,  although  in  her  case  the  latter  had  been 
the  first  to  appear,  and  had  been  replaced  after  a  six  years'  interval  by 
left  facial  neuralgia,  which  resection  of  the  nerve  failed  to  relieve. 


In  these  cases  the  condition  is  undoubtedly  one  of 
painful  facial  spasm,  inaccurately  and  unfortunately 
styled  "  tic  douloureux." 

Bruandet1  has  recorded  a  typical  example  of  right 
facial  hemispasm  consequent  on  facial  neuralgia,  in 
which,  however,  no  certain  macroscopical  or  micro- 
scopical lesion  was  detected,  in  either  cortex  or  bulb. 
But  the  mere  fact  that  no  structural  alteration  was 
discovered  post-mortem  cannot  invalidate  the  diagnosis ; 
the  imperfection  of  our  methods  of  investigation  suffices 
to  explain  the  negative  results  of  such  researches. 


B.  Tic  or  Spasm  of  the  Neck— Torticollis  Tic  and 
Torticollis  Spasm 

To  make  a  diagnosis  of  torticollis,  it  is  essential  to 
satisfy  oneself  of  the  integrity  of  the  bones,  muscles, 
and  articulations  of  the  cervico-scapular  region,  previous 
to  directing  attention  to  the  psychical  state  of  the 
patient.  In  regard  to  the  latter  point,  the  question  of 
heredity  must  not  be  neglected.  If  personal  and 
hereditary  defects  are  prominent,  the  presumption  is 
in  favour  of  mental  torticollis;  and  if  the  convulsive 

1  BRUANDET,  "  Un  cas  d'hemispasme  facial,"  Rev.  neurologique, 
1900,  p.  658.  % 


276         TICS  AND    THEIR    TREATMENT 

movements  present  the  characters  of  tic,  the  diagnosis 
is  practically  certain. 

In  three  cases  under  the  observation  of  Fornaca,1  for 
instance,  there  is  no  room  for  doubt.  Not  merely  was 
there  no  sign  of  irritation  from  peripheral  sources,  but 
also  no  one  of  the  three  was  psychically  normal. 

Nevertheless  we  frequently  find  ourselves  confronted 
by  the  question :  is  the  movement  a  tic,  or  is  it  a 
spasm  ?  For,  strictly  speaking,  there  are  both  a  torti- 
collis tic  and  a  torticollis  spasm,  and  their  separation 
one  from  the  other  is  often  a  matter  of  the  greatest 
perplexity. 

We  must  refer  the  reader  to  the  chapter  devoted 
to  mental  torticollis  for  a  consideration  of  the  features 
of  that  condition,  and  we  need  not  dwell  on  those  cases 
of  spasmodic  torticollis  that  are  obviously  occasioned 
by  irritative  lesions  of  nervous  centres  or  conductors. 
In  this  latter  category  may  be  placed  the  case  put  on 
record  by  Oppenheim,  where  torticollic  spasms  were 
produced  by  pressure  of  a  cerebellar  tumour  on  the 
cranial  nerves. 

But  in  the  affection  known  as  hyperkinesis  of  the 
accessory  of  Willis  we  have  little  doubt  both  tics  and 
spasms  have  been  included.  Apart  from  the  cases  of 
spasmodic  torticollis,  so  called,  which  Babinski  has 
published  and  to  which  reference  has  already  been 
made,  we  may  be  allowed  to  cite  one  or  two  more,  in 
order  to  exemplify  the  differences  of  interpretation  to 
which  they  are  liable. 

At  the  Congress  of  Toulouse  two  patients  were 
shown  by  Desterac,2  both  of  whom  had  suffered  since 
the  age  of  eight  from  a  disease  akin  either  to  Friedreich's 
disease  or  to  hereditary  cerebellar  ataxia. 

1  FORNACA,  Clinica  medico,  italiana,  No.  II,  1901. 
*  DESTERAC,  "  Syndrome  du  torticolis  spasmodique,"  VT   Congres 
franfais  de  medecine,  Toulouse,  April,  1902. 


DIAGNOSIS  277 

They  presented  the  spastic  gait  of  the  former  with  the  involuntary 
movements  of  the  latter,  in  addition  to  spasm  of  the  hand  in  writing, 
spasmodic  movements  of  the  trunk,  and  spasmodic  torticollis.  Both 
had  club  foot  and  scoliosis,  and  one  was  afflicted  with  spasm  of  the 
face  and  left  arm.  In  his  case,  further,  there  was  nystagmus,  together 
with  loss  of  reflexes  and  difficulty  in  articulation,  while  fibrillary  con- 
tractions were  to  be  observed  in  his  muscles.  The  other  patient's 
reflexes  were  exaggerated,  and  he  showed  a  double  extensor  response. 

In  Desterac's  opinion  their  spasmodic  torticollis  was 
dependent  on  this  congenital  constitutional  affection, 
which  might  be  regarded  as  a  fruste  form  of  one  of  the 
diseases  above  mentioned. 

Through  the  kindness  of  M.  Desterac  the  opportunity 
has  been  granted  one  of  us  of  examining  the  two 
patients,  and  we  should  like  to  point  out  why  we  think 
his  interpretation  of  their  symptoms  must  be  considered 
with  reserve. 

Speaking  generally,  we  thought  the  cases  closely 
resembled  those  in  which  a  long-standing  mental  torti- 
collis is  accompanied  with  convulsive  movements  of 
the  limbs.  The  scoliosis  was  not  permanent,  the 
deformation  of  the  foot  could  be  overcome,  and  at  the 
same  time  we  failed  to  convince  ourselves  of  the  pre- 
sence of  nystagmus  and  the  absence  of  the  knee-jerks. 
Moreover,  we  happened  to  observe  one  of  the  patients 
in  the  street  unawares,  and  remarked  how  between  two 
phases  of  bizarre  contortions  his  vicious  attitudes  and 
convulsive  gestures  almost  entirely  vanished.  In  fact, 
the  clinical  picture  seemed  to  us  to  be  quite  other  than 
that  associated  with  organic  disease  such  as  Friedreich's 
disease  or  hereditary  cerebellar  ataxia. 

Another  case  recently  brought  before  the  Neuro- 
logical Society  of  Paris  by  Marie  and  Guillain  l  serves 
even  better  to  illustrate  the  intricacies  of  diagnosis. 

1  MARIE  AND  GUILLAIN,  "  Mouvements  athetoides  de  nature  indeter- 
min£e,"  Soc.  de  neur.  de  Paris ,  April,  1902. 


278         TICS  AND   THEIR   TREATMENT 

The  patient  was  a  man  of  fifty-eight,  who  for  years  had  exhibited 
certain  movements  apparently  of  an  athetoid  nature.  His  head  was  ex- 
tended and  rotated  to  the  right  synchronously  with  elevation  and  eversion 
•of  the  left  shoulder,  then  it  passed  into  flexion.  Except  for  a  few  odd 
movements  of  the  tongue,  the  face  conserved  immobility.  In  the  arms 
the  localisation  of  the  contractions  was  mostly  proximal,  though  there 
were  alternating  flexion  and  extension  movements  of  the  fingers  which 
suggested  athetosis.  Flexion,  inversion,  and  adduction  of  the  thighs  also 
occurred.  The  recti  abdominis  were  similarly  involved. 

Under  the  influence  of  emotion  the  movements  were  increased,  but 
they  could  not  be  inhibited  by  an  effort  of  attention.  Their  rate  was 
too  slow  for  chorea.  Ordinary  voluntary  movements  were  performed 
without  apparent  trouble  ;  the  patient  was  able  to  dress  himself,  and 
to  drink  without  spilling  the  liquid.  Diminution  of  the  knee-jerks 
was  noticed,  with  what  seemed  to  be  an  extensor  response.  Slight 
scoliosis  of  the  vertebral  column  and  a  misshapen  right  foot  recalled 
Friedreich's  ataxia.  There  was  nothing  to  justify  a  diagnosis  of  hysteria. 

This  curious  condition  dated  from  the  year  1874,  when  the  patient 
had  a  febrile  attack,  in  the  course  of  which  pain  and  tingling  appeared 
in  the  toes  of  the  right  foot,  followed  by  involuntary  movements  of 
the  same  member.  Analogous  symptoms  were  not  long  in  appearing 
in  the  left  arm.  Two  months  later  the  condition  had  become  general, 
but  from  that  time  no  special  modification  took  place. 


In  the  subsequent  discussion  it  was  remarked  by 
Souques  that  the  case  resembled  one  recorded  by 
Chauffard l  as  Friedreich's  disease  with  athetotic 
attitudes,  where  the  patient  was  a  child  with  club  foot, 
diminution  of  the  knee-jerks,  and  generalised  athetotic 
movements. 

Notwithstanding  our  inability  to  assign  a  definite 
nosographical  position  to  examples  of  this  kind,  we  think 
it  desirable  to  make  some  reference  to  them,  in  the 
hope  that  further  observations  will  aid  in  their  diagnosis. 
They  at  least  remind  us  that  convulsions  occurring 
in  the  course  of  organic  disease  may  be  simulated  by 
the  manifestations  of  certain  motor  neuroses. 

1  CHAUFFARD,  "  Maladie  de  Friedreich  avec  attitudes  athfetoldes," 
Scmaine  medicate,  1893,  p.  409. 


DIAGNOSIS  279 

TICS  AND  CHOREAS 
A.  Sydenham's  Chorea 

It  would  be  difficult  to  find  a  better  description 
of  chorea  minor  than  that  given  originally  by  Sydenham 
himself : 

The  dance  of  Saint  Guy,  chorea  Sancti  Viti  in  Latin,  is  a  sort  of 
convulsion  whose  incidence  is  greatest,  in  both  sexes,  between  the  age 
of  ten  and  puberty.  Its  onset  is  characterised  by  weakness  of  one  limb, 
which  the  patient  drags  behind  him,  and  soon  the  arm  of  the  same 
side  is  affected  in  the  same  way.  He  finds  it  impossible  to  maintain 
the  same  position  of  the  arm  for  two  consecutive  moments,  however 
great  be  his  efforts  to  attain  this  object.  Before  he  can  bring  a  full 
glass  to  his  lips  he  makes  innumerable  gestures  and  antics,  as  the 
convulsive  moments  of  the  limb  deviate  it  from  one  side  to  the  other, 
until  at  length  he  has  piloted  the  glass  opposite  his  mouth,  when  he 
empties  it  at  a  gulp. 

If  we  were  to  confine  ourselves  to  this  description 
by  Sydenham,  which  so  far  as  typical  cases  of  the 
disease  are  concerned  is  perfectly  accurate,  differentia- 
tion between  tic  and  chorea  would  not  be  a  matter 
of  any  complexity.  Unfortunately,  however,  the 
varieties  of  this  form  of  chorea  are  legion,  and  in 
practice  one  constantly  meets  with  conditions  suggesting 
alike  the  gesticulations  of  chorea  and  the  convulsive 
reactions  of  tic.  Moreover,  it  has  been  pointed  out 
by  Oddo  l  that  the  fact  of  the  habitual  exaggeration 
of  tic  during  the  very  years  when  chorea  is  liable  to 
appear  is  calculated  to  confuse  the  issue. 

He  has  attempted,  however,  to  specify  certain  factors 
in  the  differential  diagnosis.  In  the  first  instance,  the 
form  of  the  movements  is  of  significance  :  there  is  no 

1  ODDO,  "  Le  diagnostic  diffe~rentiel  de  la  maladie  des  tics  et  de  la 
chor6e  de  Sydenham,"  Presse  medicale,  September  30,  1899. 


28o          TICS  AND    THEIR    TREATMENT 

co-ordination  in  the  muscular  play  of  the  choreic ;  it  is 
amorphous,  indefinable,  and  erratic,  whereas  the  gestures 
of  tic  are  purposive,  and  may  be  said  to  have  a  shape. 
One  never  sees  in  chorea  a  succession  of  similar  move- 
ments, but  though  a  patient  be  suffering  from  several 
tics,  each  of  them  is  reproduced  always  in  the  same 
fashion.  Unilaterality  of  distribution  is  more  common 
in  chorea  than  in  tic ;  in  other  words,  chorea,  more  or 
less,  follows  anatomical  lines  in  the  regions  it  affects, 
whereas  the  incidence  of  tic  is  physiological. 

Both  are  arhythmic  in  their  manifestation  ;  never- 
theless the  repetition  of  tic  is  noteworthy  for  its 
regularity  as  compared  with  the  changing  mode  and 
rate  of  the  other.  Noir  emphasises  the  diagnostic 
value  of  its  frequency,  abruptness,  and  reiteration  of 
identical  movements.  In  a  majority  of  cases  the  inter- 
ference of  the  will  is  futile  as  far  as  chorea  is  concerned, 
while  the  victim  to  tic  is  usually  capable  of  restraining 
his  muscular  activity  at  least  for  a  space.  The  choreic 
exhibits  his  movements  in  public,  but  the  liqueur  seeks 
the  seclusion  of  his  own  room.  The  association  of  tic 
with  obsessional  ideas  is  frequently  encountered,  but 
there  is  no  similar  connection  between  obsessions  and 
chorea.  In  addition,  the  myasthenia,  pains,  and  altera- 
tions in  the  reflexes  that  often  characterise  chorea  are 
awanting  in  the  other  affection, 

It  cannot  be  gainsaid,  however,  that  the  frequency 
with  which  atypical  varieties  of  chorea  occur  is  inimical 
to  a  ready  diagnosis,  and  the  onerous  nature  of  the 
task  is  not  lessened  by  the  circumstance  that  many 
choreics  are  the  offspring  of  neuropathic  parents  and 
reveal  psychical  anomalies  comparable  to  those  of  the 
subjects  of  tic. 

In  a  disease  such  as  variable  chorea,  which  has 
features  in  common  both  with  tic  and  with  chorea 
properly  so  called,  the  problem  of  diagnosis  is  still  more 


DIAGNOSJS  281 

complicated,  though,  excellent  hints  for  its  solution  have 
been  furnished  by  Brissaud.1 

However  frequently  and  warmly  the  theory  of  the  origin  of  chorea 
in  a  neuropathic  predisposition  was  advocated  by  Charcot,  the  fact  of 
its  usual  evolution  consecutive  to  some  toxic  or  infective  process  is  no 
less  certain.  Its  incidence  is  greatest  in  children  and  the  adolescent  ;  it 
runs  a  regular  course  of  increase  and  decrease  ;  and  the  circumstances 
which  cause  the  symptoms  to  vary  during  this  cycle  are  never  sufficiently 
potent  to  bring  about  even  transitory  suppression  of  them. 

It  is  true  that  changes  in  the  intensity  of  the  symptoms  seem  to 
confer  a  remittent  character  on  the  affection,  but  there  is  nothing  at 
all  comparable  to  the  sudden  and  unexpected  waxing  and  waning  of 
the  form  of  chorea  at  present  under  consideration.  None  of  the  patho- 
logical attributes  just  mentioned  concerns  variable  chorea,  which,  in 
addition,  differs  from  Sydenham's  chorea  in  two  points — the  multiplicity 
of  the  types  of  movement,  and  the  fact  that  the  patient  can  voluntarily 
check  his  involuntary  actions.  For  these  reasons,  assimilation  of  the  two 
clinical  varieties  is  impossible,  and  the  confusion  of  the  two  in  practice 
need  never  occur. 

A  form  of  chorea  entitled  "  habit  spasm  "  by  Gowers, 
and  "  habit  chorea "  by  "Weir  Mitchell,  has  been  the 
subject  of  further  study  by  Sinkler,2  but  in  all  probability 
the  cases  of  this  description  reported  are  instances 
of  the  variable  chorea  of  Brissaud. 


B.   Huntingdon's   Chorea 

In  spite  of  the  preponderating  etiological  significance 
of  heredity  and  the  constancy  of  psychical  imperfections 
in  the  chronic  chorea  of  Huntington,  its  confusion 
with  tic  is  not  at  all  likely  to  occur.  Difficulties  might 
arise  in  distinguishing  chorea  major  from  variable 
chorea,  however,  and  here  we  have  the  views  of 
Brissaud  to  help  us. 

1  BRISSAUD,  "La  choree  variable  des  d6ge~neres,"  Rev.  neur.,  1896, 

P-  417- 

8  SINKLER,   "  Habit  Chorea,"  Amer.  Journ,  of  the  Med.  Sciences, 
May,  1897,  p.  559- 


282          TICS  AND    THEIR   TREATMENT 

True  chronic  chorea  is  an  incurable  neurosis,  of  life-long  duration. 
We  have  no  trouble  in  pronouncing  a  diagnosis  of  chronic  chorea  if 
the  symptoms  date  back  five,  ten,  or  twenty  years,  but  they  must  have 
had  a  commencement,  and  the  whole  problem  is  to  foretell  the  course 
of  a  chorea  as  yet  only  a  few  weeks  or  months  old. 

The  involuntary  movements  of  chronic  chorea,  like  those  of  Sydenham's 
chorea,  are  illogical,  but  they  are  combined  in  a  co-ordinate  manner — 
that  is  to  say,  certain  functionally  associated  muscular  groups  act  simul- 
taneously as  for  a  particular  end  :  the  patient  shrugs  his  shoulders,  closes 
his  fists,  cracks  his  fingers,  utters  cries,  he  swallows,  sniffs,  sucks  in  his 
breath,  makes  the  sound  of  kissing,  etc.,  in  all  of  which  actions  orderly 
participation  of  the  musculature  in  a  foreordained  way  is  evident.  Slight 
twitching  of  individual  muscles  and  parts  of  muscles  also  occurs. 

There  is  no  limitation  of  the  movements  to  a  special  division  of 
the  body  ;  on  the  contrary,  they  spread  from  one  muscle  to  another, 
and  from  one  segment  to  another,  rapidly  and  arhythmically.  The 
gait  is  by  turns  skipping,  dancing,  or  stumbling,  interrupted  by  falls 
or  by  abrupt  jerks  of  the  loins.  Speech  is  uncertain  or  monotonous  ; 
writing  is  incorrect  and  badly  formed,  sometimes  illegible.  A  fact  of 
the  utmost  importance  is  that  all  these  involuntary  movements  may  be 
modified,  abated,  relieved,  so  to  speak,  by  voluntary  movements  in  an 
inverse  direction.  In  some  cases  the  power  of  willing  is  still  sufficiently 
developed  to  permit  of  the  patient's  following  his  occupation. 

The  steadily  progressing  increase  in  the  seriousness 
of  the  motor  trouble,  paralleled  by  progressing  mental 
deterioration,  is  one  of  the  most  significant  factors  in 
the  differential  diagnosis.  It  is  precisely  the  variability 
of  the  symptoms  that  distinguishes  variable  chorea. 

C.   Hysterical    Chorea 

The  conditions  to  which  the  name  of  hysterical 
chorea  is  applied  may  assume  two  forms,  the  commoner 
being  known  as  rhythmical  chorea,  the  other  as 
arhythmical  chorea.  In  the  former  case  the  convulsive 
movements  are  usually  unilateral,  being  confined  some- 
times to  a  single  limb,  and  reproducing,  for  instance, 
the  actions  of  dancing  (saltatory  chorea),  or  of  swimming 
(natatory  chorea),  or  such  professional  movements  as 
those  of  the  blacksmith  (choree  malliatoire).  Occasionally 


DIAGNOSIS  283 

there  is  a  more  or  less  faithful  reproduction  of  deliberate 
and  purposive  acts  in  the  form  of  attacks  of  varying 
duration,  recurring,  moreover — and  this  is  their  cardinal 
feature — at  equal  intervals. 

Under  the  title  of  disease  of  the  tics  two  cases 
have  been  published  by  Nonne,1  the  first  consisting  of 
rhythmical  twitches  in  a  man  of  forty  years,  secondary 
to  a  head  injury,  the  other  presenting  similar  appear- 
ances, but  concerning  a  young  girl  of  eighteen  years 
who  had  sustained  a  shock.  In  neither  was  there  any 
sign  of  hysteria.  The  reporter  animadverts  on  the 
designation  "  rhythmical  chorea,"  and  protests  that 
the  systematisation  and  co-ordination  of  the  movements 
are  very  different  from  the  clinical  picture  of  Sydenham's 
chorea,  while  their  rhythmical  nature  does  not  allow 
of  their  being  classified  as  tic. 

Sometimes  hysterical  chorea  is  arhythmical — that  is 
to  say,  the  movements  are  irregular  and  contradictory, 
as  in  ordinary  chorea.  True  chorea  in  cases  of  hysteria 
comes  under  this  heading,  as  well  as  those  cases  where 
hysterical  patients  imitate  the  movements  of  chorea. 
The  presence  of  the  distinctive  characters  of  hysteria 
makes  a  diagnosis  of  tic  improbable. 

The  separation  of  hysterical  from  variable  chorea 
may  be  peculiarly  perplexing,  as  in  one  of  Brissaud's 
cases,  where  the  patient's  extraordinary  mental  in- 
stability was  such  as  is  encountered  only  in  advanced 
hysteria,  while  her  disorders  of  motility  were  highly 
characteristic  of  what  is  known  as  variable  chorea. 

The  condition  described  as  chorea  gravidarum  may 
be  placed  at  one  time  in  the  category  of  hysterical 
chorea,  at  another  in  that  of  ordinary  chorea.  In  it  there 
is  intense  motor  restlessness,  and  accompanying  mental 
.symptoms  are  not  awanting  in  a  majority  of  instances. 

1  NONNE,  "Zwei  Falle  von  '  Maladie  des  Tics,' "  Neurolog.  Centralbl., 
1898,  p.  327. 


284          TICS  AND    THEIR    TREATMENT 

D.   Electric  Chorea,  Bergeron's  Chorea,  Dubini's  Chorea, 
Fibrillary  Chorea  of  Morvan 

To  render  the  study  complete,  we  may  remind 
ourselves  of  those  still  imperfectly  differentiated  forms 
known  as  electric  chorea  (He'noch-Bergeron)  and  Dubini's 
chorea. 

Bergeron's  chorea  affects  children  chiefly,  and  is 
characterised  by  the  suddenness  of  its  onset  and  the 
rapidity  with  which'it  attains  its  maximum.  The  move- 
ments are  abrupt  and  brief,  as  though  produced  by  an 
electric  discharge  at  regular  intervals,  but  their  intensity 
does  not  hinder  the  execution  of  voluntary  acts.  They 
are  sometimes  confined  to  the  head  and  limbs,  most 
commonly  they  are  generalised,  and  during  sleep  they 
disappear. 

In  the  opinion  of  many,  Bergeron's  chorea  is 
secondary  to  gastric  disturbance.  A  cure  may  be 
regarded  as  certain,  and  indeed  frequently  follows  the 
administration  of  an  emetic.  Sometimes  the  effect  of 
the  latter  seems  to  be  purely  psychical. 

Pitres  thinks  that  this  condition,  as  well  as  the 
electrolepsy  of  Tordeus,  is  simply  a  manifestation  of 
infantile  hysteria.  According  to  Noir,  there  is  an 
affinity  between  tic  and  electric  chorea,  and  Ricklin 
is  inclined  to  consider  the  two  identical,  but  further 
study  of  the  question  is  desirable. 

Dubini's  chorea  is  ushered  in  by  pains  and  aches 
in  the  region  of  the  head,  neck,  and  sometimes  the 
loins,  and  these  are  succeeded  by  electric-like  twitches 
in  the  segment  of  a  limb,  which  quickly  become  general. 
Severe  convulsive  attacks  also  occur,  without  loss  of 
consciousness,  entailing  actual  paresis  of  the  limbs. 
The  duration  of  the  disease  may  be  days  or  months, 
and  90  per  cent,  of  the  cases  have  a  fatal  issue- 
Confusion  with  tic  is  impossible. 


DIAGNOSIS  285 

"We  need  not  concern  ourselves  with  so-called 
paralytic  chorea,  or  with  the  fibrillary  chorea  of 
Morvan,  which  is  a  disease  of  adolescence,  characterised 
by  fibrillary  contractions  in  the  calves  and  thighs, 
passing  thence  to  the  trunk  muscles  and  even  to 
the  arms ;  the  face  and  neck,  however,  are  spared,  and 
during  voluntary  movement  the  fibrillation  vanishes. 
Probably  it  is  merely  a  variety  of  the  paramyoclonus 
of  Friedreich. 


TIC  AND  PARAMYOCLONUS  MULTIPLEX— TIC    AND 
MYOCLONUS 

It  is  not  our  intention  here  to  seek  to  provide 
a  differential  diagnosis  between  tic  and  the  various 
conditions  usually  classed  as  myoclonus",  and  that  for 
two  reasons  :  in  the  first  place,  we  cannot  admit  that 
the  latter  form  a  distinct  clinical  or  nosographical  entity, 
since  the  term  myoclonus  seems  simply  to  be  an 
abbreviation  for  clonic  muscular  convulsion,  and  is  a 
symptom  rather  than  a  clinical  syndrome ;  secondly, 
the  fact  that  the  tics  themselves  have  been  incorporated 
with  myoclonus  involves  the  investigation  of  all  the 
published  cases  with  a  view  to  their  critical  sifting. 
This  task  we  have  pursued  for  our  own  edification,  but 
to  enter  on  it  here  would  serve  no  useful  purpose,  and 
we  shall  rest  content  with  examining  succinctly  several 
recent  cases  described  as  myoclonus,  in  the  hope  that 
the  prosecution  of  further  research  will  introduce  order 
into  what  is  at  present  chaos. 

Among  the  various  forms  of  myoclonus  there  is  one 
which  presents  a  certain  individuality,  and  which  was 
described  originally  by  Friedreich  under  the  name  of 
paramyoclonus  multiplex. 

This  disturbance  of  motility  supervenes,  in  patients 


286          TICS  AND   THEIR    TREATMENT 

with  a  neuropathic  heredity,  after  some  psychical 
accident  such  as  a  sudden  fright  or  emotion,  and  con- 
sists in  clonic  muscular  convulsions  affecting  the  body 
generally,  with  the  exception  of  the  face.  The  con- 
tractions appear  without  obvious  cause  in  one  or  in 
several  muscles,  are  instantaneous,  involuntary,  and 
usually  bilateral,  but  their  most  important  feature  is 
their  inequality  and  irregularity.  They  may  or  may 
not  effect  displacement  of  the  limbs ;  in  any  case  they 
compose  neither  gesture  nor  gesticulation.  Volition 
occasionally  seems  to  have  some  transient  inhibitory 
influence  over  them ;  they  are  exaggerated  by  cold  and 
by  emotion,  and  usually  disappear  in  sleep. 

It  is  obvious  that  this  account  of  a  typical  case 
precludes  the  possibility  of  any  confusion  with  tic,  but 
the  published  cases  are  not  always  in  conformity  with  it. 

In  1892  Lemoine  l  reported  a  case  where  the  move- 
ments of  paramyoclonus  multiplex  were  accompanied 
with  echolalia  and  psychical  changes.  Raymond  quotes 
an  instance  of  the  disease  being  preceded  by  facial  tic, 
and  another  associated  with  tremor  and  choreic  move- 
ments. 

D'Allocco 2  has  recorded  twenty-four  cases  of  differing 
forms  of  myoclonus,  of  which  nineteen  occurred  as 
a  family  disease,  in  conjunction  with  stigmata  of  de- 
generation, epilepsy,  and  hysteria. 

In  a  patient,  aged  twenty-six,  suffering  from  general 
paralysis,  Hermann3  noted  the  presence  of  abrupt, 
irregular,  myoclonic  twitches  in  the  sternomastoids, 
recti  abdominis,  adductors,  and  in  some  of  the  toes  and 

1  LEMOINE,  "  Note  sur  un  cas  de  paramyoclonus  multiplex  suivi 
des  troubles  psychiques  et  de  1'echolalie,"  Rev.  de  medecine,  1892, 
p.  882. 

1  D'ALLOCCO,  "  Parecchi  casi  di  mioclonia,  la  maggior  parte 
familiari,"  Riforma  medico,  vol.  i.  1897,  p.  223. 

*  HERMANN,  "  Myoklonische  Zuckungen  bei  progressive!  Para- 
lyse," Neurolog.  Centralbl.,  June  I,  1901,  p.  498. 


DIAGNOSIS  287 

fingers,  first  on  one  side  and  then  on  the  other,  also  in 
both  legs,  and  subsequently  in  both  arms,  the  face 
being  unaffected. 

Jancowicz  considers  diagnosis  possible  only  in  typical 
cases,  and  expresses  the  opinion  that  paramyoclonus  is 
a  syndrome  common  to  many  affections.  Further, 
Schupfer  makes  the  perfectly  justifiable  remark  that 
under  this  denomination  have  been  included  cases  of 
chorea,  tic,  hysteria,  and  rhythmic  spasm ;  others  have 
been  secondary  to  organic  disease  of  the  cerebrospinal 
axis,  such  as  rolandic  lesions,  spinal  muscular  atrophy, 
chronic  poliomyelitis,  syringomyelia.  Others,  again, 
depend  on  one  or  other  of  the  psychoses,  others  on 
infective  conditions  such  as  malaria,  diphtheria,  typhoid, 
or  on  intoxications  such  as  uraemia,  mercurialism,  or 
lead  poisoning.  Only  a  few  recorded  cases  cannot  be 
attributed  to  any  of  the  conditions  enumerated  above, 
hence  Schupfer' s  objection  to  the  promiscuous  classifica- 
tion of  them  all  as  paramyoclonus  multiplex  is  quite 
warranted,  in  the  absence  of  a  uniform  etiology  and 
symptomatology. 

Schultze1  has  suggested  the  term  monoclonus  for 
the  tics,  and  he  distinguishes  monoclonus,  polyclonus, 
and  paraclonus.  Embraced  in  the  last  of  these  is 
the  paramyoclonus  of  Friedreich,  which,  according  to 
Schultze,  is  usually  unilateral,  voluntary  action  dimin- 
ishing the  intensity  of  the  involuntary  movements, 
whereas  the  converse  is  the  case  in  tic  or  monoclonus. 
Mixed  forms  are  met  with,  however,  and  Schultze  him- 
self mentions  one  in  which  the  movements  were  bilateral 
and  increased  with  voluntary  activity. 

Heldenberg 2  applies  the  term  intermittent  functional 

1  SCHULTZE,  "  Ueber  Chorea,  Poly-  und  Monoklonie,"  Neurolog. 
CentralbL,  1897,  p.  611. 

2  HELDENBERG,     "Myoclonus    fonctionnel    intermittent,"  Semaine 
medtcale,  1899,  p.  194. 


288          TICS  AND    THEIR    TREATMENT 

myoclonus  to  twitches  occurring  from  time  to  time 
in  antagonistic  muscles  during  voluntary  movement, 
twitches  exaggerated  by  excitement  and  diminished 
with  rest.  They  occur  in  combination  with  well-marked 
vasomotor  phenomena. 

The  myokymia  of  Kny  and  Schultze  is  characterised 
by  fibrillation,  pain,  hyperidrosis,  and  changes  in 
electrical  excitability. 

A  case  which  seemed  to  be  a  combination  of  para- 
myoclonus  with  Thomson's  disease  has  been  reported  by 
Hajos  1  under  the  title  myospasmia  spinalis. 

There  cannot  possibly  be  any  hesitation  in  arriving 
at  a  diagnosis  between  tonic  tic  and  Thomson's  disease, 
a  condition  consisting  in  slowness  of  relaxation  of  a 
strongly  contracted  muscle,  and  conceivably  due  to 
defective  metabolism  or  organic  change  in  muscular 
tissue.8 

Examples  such  as  the  above,  culled  at  random  from 
an  abundant  medical  literature,  and  variously  entitled, 
will  serve  to  demonstrate  the  protean  nature  of  what 
the  medical  world  is  content  to  call  myoclonus,  and 
if  from  this  collection  of  motor  disorders  we  may  hope 
to  extricate  the  tics,  there  will  remain  still  no  incon- 
siderable labour  of  differentiation  for  the  student. 


TIC  AND  ATHETOSIS 

The  athetotic  movements  that  may  accompany 
hemiplegia  are  scarcely  likely  to  be  confused  with  those 
of  tic,  but  difficulties  may  arise  where  the  athetosis  is 
double. 

It  has   been   universally   remarked    that    athetotic 

1  HAJOS,  "  Ein  Fall  von  Myospasmia  Spinalis,"  Ungar.  med. 
Prtssf,  1898,  No.  34. 

»  BECHTEREW,  "Myotonie  eine  Krankheit  des  Stoffwechsels," 
Neurolog.  Centralbl.,  1900,  p.  98. 


DIAGNOSIS  289 

movements  of  the  face  reproduce  the  expression  of 
emotions,  such  as  admiration,  astonishment,  sorrow, 
gaiety,  etc.  Of  course  the  same  may  be  said  of  the 
grimaces  of  chorea ;  the  latter,  however,  are  usually 
more  abrupt  and  pass  less  readily  one  into  the  other. 
The  gesticulations  of  athetosis  are  undulatory,  so  to 
speak,  and  their  excess  leads  to  deformities  principally 
in  the  direction  of  forced  extension.  The  musculature 
is  often  rigid,  and  the  reflexes  are  increased  in  activity. 
Sometimes  there  is  a  considerable  degree  of  mental 
disturbance. 

Now,  it  is  precisely  in  cases  where  mental  deteriora- 
tion is  a  prominent  feature  that  "  nervous  movements" 
have  been  described  resembling  those  of  athetosis,  for 
which  the  term  pseudo-athetosis  has  been  coined.  Two 
examples  may  be  quoted  from  Noir. 

E.  is  a  girl  of  eleven  years.  Her  expression  is  grimacing  ;  her  tongue 
is  often  protruded,  but  never  bitten  ;  her  head  is  regularly  flexed  or 
extended,  or  rotated  rhythmically  to  left  or  right.  The  arms  are 
moved  spasmodically  at  shoulder  and  elbow,  while  the  hands  are  the 
seat  of  athetotic  movements.  She  walks  curiously,  throwing  her  feet 
out  in  advance  without  bending  her  knees.  She  has  a  silly  smile,  and 
her  mouth  almost  invariably  hangs  open.  On  request  she  can  keep 
her  hands  quite  steady,  but  one  observes  at  once  the  effort  this  entails 
in  the  sudden  seriousness  of  her  expression.  The  ordinary  acts  of  every- 
day life  are  performed  satisfactorily  enough  :  she  can  dress  and  undress, 
use  a  knife  and  fork,  thread  a  needle,  sew,  etc. 

J.  is  eleven  years  old  also.  She  puckers  her  lips,  contracts  her 
eyebrows,  elevates  her  alae  nasi  ;  at  the  same  time  she  exhibits  pseudo- 
athetotic  movements  of  her  fingers  which  are  entirely  under  voluntary 
control. 

The  question  may  indeed  be  asked  whether  pseudo- 
athetosis  and  variable  chorea  are  not  really  identical. 
Further,  all  sorts  of  combinations  of  athetosis  and 
myotonia  have  been  noted,1  but  more  light  must  be 

1  KAISER,  "  Myotonische  Storungen  bei  Athetose,"  Neurolog. 
Centralbl.,  1897,  p.  674. 

19 


290          TICS  AND    THEIR   TREATMENT 

shed  on  the  subject  before  any  further  classification  can 
be  attempted. 

The  following  case  has  recently  been  published  by 
Marina '  : 

A  blacksmith,  aged  seventeen  years,  already  treated  three  times  for 
recurrent  chorea,  suffered  from  slow  contractions  of  the  shoulder  muscles, 
involving  the  elevators  and  internal  and  external  rotators  successively,  and 
accompanied  by  movements  of  the  head  and  arm,  and  by  twitches 
of  the  quadriceps.  Nothing  seemed  to  have  any  influence  over  these 
movements  except  sleep.  The  faradic  excitability  of  the  shoulder  muscles 
was  augmented,  the  galvanic  excitability  diminished.  Application  of 
the  constant  current  to  the  head  and  back  sufficed  to  effect  a  cure  in 
three  weeks. 

Marina  proposes  the  term  athetotic  myospasm  for 
these  incessant  slow  alternating  contractions,  impulsive 
myospasm  being  employed  to  signify  convulsive  move- 
ments of  more  than  one  muscular  group,  purposive 
yet  irresistible,  as  in  tic  and  chorea  major.  Simple 
myospasm  consists  of  single  twitches  in  individual 
muscles,  recalling  those  produced  by  electrical  excita- 
tion. If  several  muscles  are  implicated,  the  condition  is 
one  of  multiple  myospasm  or  myoclonus. 

TICS    AND    TREMORS 

All  tremors,  whether  they  occur  during  muscular 
repose  or  muscular  activity,  are  distinguished  by  the 
relative  restriction  of  their  range  and  the  regularity  of 
their  time.  The  tremors  of  paralysis  agitans,  dis- 
seminated sclerosis,  senility,  toxaemia,  hysteria,  ex- 
ophthalmic goitre,  etc.,  are  not  liable  to  be  mistaken 
for  tic. 

It  is  true,  of  course,  that  tremor  is  sometimes 
combined  with  choreiform  or  athetotic  movements  in 

1  MARINA,  "  Delle  miospasie  in  generate  e  della  miospasia  atetosica 
in  particolare,"  II policlinico,  1902,  p.  577. 


DIAGNOSIS  291 

patients  with  psychical  stigmata.1  A  proposal,  too,  has 
been  made  to  unite  hereditary  and  functional  tremor 
and  to  describe  them  as  a  tremor  neurosis.2 

However  simple  be  the  diagnosis  between  tremor 
and  tic,  it  is  worth  while  to  note  in  passing  the  etiology 
they  may  have  in  common.  In  a  case  recorded  by  van 
Grehuchten  an  intention  tremor  of  the  right  arm  co- 
existed with  a  tic  of  the  right  sternomastoid. 

A  sudden  twitch  of  the  whole  body  Letulle  par- 
ticularises as  a  "  tic  of  starting,"  and  Noir  too  thinks 
that  a  start  of  this  nature  may  constitute  a  tic,  but 
we  are  inclined  to  consider  it  a  generalised  reflex. 

TICS    AND    PROFESSIONAL    CRAMPS 

We  have  already  had  occasion  to  enlarge  on  the 
distinguishing  features  of  professional  or  occupation 
cramps,  spasms,  or  neuroses.  Writers,  pianists,  violin- 
ists, flutists,  dressmakers,  telegraphists,  watchmakers, 
milkers,  knackers,  blacksmiths,  shoemakers,  tailors, 
dancers,  embroiderers,  barbers,  etc.,  etc.,  are  all  liable 
to  suffer  from  occupation  cramps.  In  every  case  the 
condition  is  one  of  inability  to  perform  the  professional 
movement,  and  that  alone. 

Grasset  proposes  to  separate  intra-professional  from 
post-professional  spasm,  the  former  consisting  in  the 
impossibility  of  making  the  necessary  professional 
movements,  the  latter  in  the  involuntary  over-reproduc- 
tion of  the  familiar  act.  Properly  speaking,  the  post- 
professional  spasm  is  a  tic. 

We  need  not  do  more  than  remind  the  reader  of  the 
close  affinities  we  have  already  seen  to  exist  between 

1  LABBE,  Presse  medicale,  1897,  p.  185  ;   MILLS,  Journ.  of  Nervous 
and  Mental  Disease,  1879,  p.  504. 

2  ACHARD  AND  SOUPAULT,   "  Tremblement  h6r6ditaire  et  tremble- 
ment  senil,"  Gazette  heddomadaire,  1897,  p.  373. 


2Q2          TICS  AND    THEIR    TREATMENT 

tics  and  professional  cramps,  and  of  the  mental  insta- 
bility which  both  classes  of  patient  present. 

L.  supplies  an  instance  of  variable  hemichorea 
followed  by  writers'  cramp  and  later  by  mental  torti- 
collis. 

When  L.  was  eight  years  old  choreiform  movements  of  the  right 
arm  began  to  appear,  and  soon  rendered  writing  an  impossibility.  The 
disease  continued  for  so  long  a  time  that  one  might  not  unreasonably 
expect  to  find  considerable  actual  impairment  of  her  caligraphy.  As  a 
matter  of  fact,  it  is  scarcely  affected  :  the  patient  can  make  her  letters 
correctly,  but  after  each  letter  she  lifts  her  pen  to  allow  her  fingers 
to  perform  an  abrupt  movement,  then  she  proceeds. 

It  cannot  therefore  be  considered  a  true  writers'  cramp,  but  when 
she  had  learnt  to  write  with  the  other  hand  it  was  not  long  ere  that  became 
the  seat  of  a  genuine  cramp.  The  moment  she  attempted  to  make 
the  pen  move  over  the  paper  her  grasp,  of  it  tightened  and  her  fingers 
stiffened  ;  her  wrist  would  no  longer  answer  her.  To  obviate  the  trouble 
she  used  a  pencil,  at  first  with  complete  success  ;  but  the  cramp  occurred 
afresh,  and  she  gave  up  writing  altogether.  Prolonged  holidaying, 
however,  and  respite  from  the  exercise,  had  a  salutary  effect,  and  to-day 
there  is  no  trace  of  former  mischief. 


L.IBR  ARV 

STATE  h'JUYM.  SCHOOL 
MANUAL  ARTS  AM,-  HOVE 

S»NTA  BAR3ASA.  CAUFOHH1A 


CHAPTER    XVII 

PROGNOSIS 

THE  prognosis  in  a  case  of  tic  depends  solely  on 
the  mental  state  of  the  patient.  After  what  has 
been  said  of  the  role  played  by  psychical  disorders  in 
the  genesis  of  tic,  we  can  readily  comprehend  the 
reason  for  this.  The  intensity  and  tenacity  of  any  tic 
are  determined  by  the  degree  of  volitional  imperfection 
to  which  its  subject  has  sunk.  He  who  can  will  can 
effect  a  cure ;  be  it  a  simple  tic,  or  be  it  a  case  of 
Gilles  de  la  Tourette's  disease,  if  he  can  struggle  long 
and  energetically,  the  tic's  doom  is  sealed.  Permanent 
cures  have  undoubtedly  been  obtained,  but  they  are 
the  exception.  Left  to  himself,  the  victim  to  tic  can 
seldom  escape  from  it. 

As  far  as  life  is  concerned,  tics  are  harmless,  yet, 
according  to  Gilles  de  la  Tourette,  the  prognosis  is 
by  no  means  always  unchanging. 

The  establishment  of  a  tic  is  never  followed  by  its  ultimate  disappear- 
ance ;  it  may  be  modified  in  all  sorts  of  ways,  yet  the  expert  observer 
will  not  fail  to  mark  its  presence.  A  complete  cure  is  not  to  be  expected, 
for  however  much  paroxysms  may  be  alleviated  and  their  frequency  re- 
duced, the  morbid  condition  has  become  a  sort  of  function,  a  product 
of  the  patient's  mental  constitution. 

The  statement  may  be  taken  to  imply  that  no  tic 
abandoned  to  itself  ever  vanishes  completely,  but  the 
generalisation  is  inaccurate.  Systematic  treatment  may 

293 


294          TICS  AND   THEIR   TREATMENT 

lead  not  only  to  amelioration,  but  also  to  cure.  Certain 
tics  of  children  are  by  nature  ephemeral,  and  disappear 
spontaneously,  never  to  return.  It  is  easy  to  understand 
how  that  may  be.  Psychical  evolution  and  physical 
evolution  alike  are  liable  to  singular  variations.  Hence 
the  development  of  a  tic  in  early  life  is  no  reason  for 
despair,  seeing  that  we  are  not  justified  in  the  assumption 
that  the  volitional  debility  which  it  proclaims  is  to 
persist.  We  must  believe  that  volition  may  be  rein- 
forced, and  we  must  further  the  attainment  of  this  end 
by  every  means  at  our  disposal.  Negligence  on  our  part 
is  highly  culpable. 

Tics  of  childhood  are  curable :  we  draw  attention 
to  the  fact  afresh.  Their  spontaneous  dissolution  is 
not  unknown,  but  parents  must  not  consider  the  question 
merely  one  of  time.  They  must  impress  on  their 
children  the  sobering  effect  of  good  behaviour  and 
decorum.  Discipline  of  this  kind  may  be  a  long  and 
delicate  task,  but  to  condone  indulgence  in  untimely 
movements,  on  the  pretext  that  they  are  merely  quaint, 
is  a  mistake  fraught  with  the  gravest  consequences. 

When  a  child  holds  its  knife  or  fork  incorrectly, 
or  puts  its  elbows  on  the  table,  or  its  finger  in  its  nose, 
we  feel  that  the  habit  is  displeasing;  but  how  much 
more  serious  the  outlook  if  the  trick  consists  in  biting 
the  lips,  or  tossing  the  head,  or  blinking  the  eyes ! 
The  former  is  an  offence  against  good  taste  ;  the  latter 
is  a  tic  in  embryo. 

It  may  be  said,  as  a  general  rule,  that  the  chances 
of  spontaneous  cure  are  in  inverse  proportion  to  the 
age  of  the  patient  and  the  duration  of  his  tic. 

Tics  of  adult  life  may  also  be  cured,  less  often,  it 
is  true,  than  in  the  case  of  children,  j  Oppenheim  gives 
the  history  of  a  woman  with  a  rebellious  facial  tic  of 
twelve  years'  duration,  which  ceased  on  the  occasion 
of  a  certain  happy  event  in  the  family  {life.  Of  course 


i 


PROGNOSIS  295 

one  wants  to  know  whether  it  ever  returned,  for  many 
so-called  cures  are  simply  remissions. 

T.  had  suffered  from  torticollis  for  a  whole  year, 
but  on  the  eve  of  her  son's  marriage  it  stopped  entirely 
for  three  days,  and  she  deemed  the  cure  permanent ; 
it  was  not  long,  unfortunately,  ere  she  underwent  a 
relapse. 

Brissaud l  quotes  an  instructive  case  of  temporary 
cessation  of  tic.  A  patient  afflicted  with  mental 
torticollis  of  three  years'  standing  learned  that  his  son 
had  been  injured  and  had  been  removed  to  hospital  to 
undergo  an  operation.  In  an  instant  his  torticollis 
disappeared,  but  a  reassuring  report  from  the  surgeon 
a  few  days  later  was  followed  by  a  recrudescence  of 
the  condition. 

It  is  true  a  hardened  tiqueur  may  be  relieved  of  his 
tic,  but  the  potentiality  remains.  He  is  still  at  the 
mercy  of  the  impulse  to  tic,  should  it  arise.  Cruchet 
gives  the  history  of  a  young  man  who  suffered  in 
succession  from  convulsive  movements  of  negation, 
facial  tic,  blinking  of  the  eyes,  abrupt  yawning, 
and  twitches  of  the  shoulder — all  in  the  space  of  two 
years.  Each  disappeared  in  its  turn,  independently  of 
treatment,  without  leaving  any  trace  behind.  In  cases 
of  this  description  a  new  tic  is  ever  imminent.  The 
facility  with  which  one  tic  replaces  another  is  a  matter 
of  common  observation.  We  have  often  had  occasion 
to  observe  relapses,  or  partial  relapses,  in  which  an 
altogether  new  tic  suddenly  makes  its  appearance  on 
the  top  of  one  which  has  either  been  improving  or  has 
actually  been  checked. 

Apart,  however,  from  obdurate  forms  of  long 
standing,  especially  such  as  are  accompanied  by  signs 
of  grave  mental  defect,  we  maintain  that  the  subjection 

1  BRISSAUD,  "Centre  le  traitement  chirurgical  dutorticolis  mental," 
Rev.  neurologiqtie,  1897,  p.  34. 


296         TICS  AND   THEIR   TREATMENT 

of  patients  to  appropriate  treatment  for  an  adequate 
period  has  a  favourable  influence  on  prognosis.  The 
curability  of  tic  was  denied  by  Oddo,  but  he  has 
recently  seen  fit  to  change  his  opinion,  and  to  confine 
his  pessimistic  views  to  Gilles  de  la  Tourette's  disease. 

The  prognosis  of  the  mental  state  of  victims  to 
tic  is  outwith  our  province :  it  is  a  topic  long  since 
handled  by  psychiatrists.  We  may  ask,  however, 
whether  any  particular  prognostic  import  is  to  be 
attached  to  the  tics  themselves. 

In  cases  of  Gilles  de  la  Tourette's  disease  the  pro- 
gressive unfolding  of  motor  disorders  suggests  a 
corresponding  evolution  of  psychical  derangements 
which  may  end  in  dementia.  Brissaud  warns  us  that 
in  cases  of  mental  torticollis  we  must  be  on  our  guard 
against  the  apparition  of  some  much  more  redoubtable 
affection  than  the  torticollis,  for  that,  sometimes,  is  an 
incident  in  the  prodromal  stage  of  general  paralysis  of 
the  insane.  Seglas  has  had  a  case  of  aerophagic  tic 
which  eventually  became  one  of  general  paralysis, 
and  a  similar  instance  occurred  in  the  practice  of  one 
of  us. 

Not  long  ago  Dufour1  advanced  the  opinion  that 
the  occurrence  of  a  motor  syndrome  consisting  of  the 
automatic  movements  of  tic,  in  a  case  of  delusional 
insanity,  heightens  the  gravity  of  the  prognosis  as 
regards  chronicity.  It  had  been  already  remarked  by 
Morel  that  such  of  the  insane  as  contract  tics  usually 
degenerate  into  dements.  Most  of  the  contributors  to 
the  study  of  idiocy  have  noted  the  relation  between 
the  degree  of  intellectual  debility  and  the  extent  of  the 
automatic  and  rhythmical  movements. 

In  this  connection  Joffroy  has  made  some  interesting 
statements. 

1  DUFOUR,   "A   propos   des    tics    et   troubles   moteurs    chez    les 
delirants  chroniques,"  Soc.  de  neur.  de  Paris,  November  7,  1901. 


PROGNOSIS  297 

Sometimes  there  is  not  merely  co-existence,  but  an  actual  parallelism 
between  the  motor  and  the  psychical  disturbance.  I  have  under  observa- 
tion at  present  a  young  woman  suffering  from  attacks  of  agitation,  with 
delusions  and  hallucinations,  who  has  developed  a  facial  tic  in  the  course 
of  her  psychosis,  and  increase  in  the  violence  of  the  tic  is  associated  with 
abrupt  utterance  of  imperfectly  formed  syllables.  During  the  last  two 
months  she  has  been  having  attacks  in  the  evening,  when  the  psychical 
troubles  have  become  more  intense,  and  simultaneously  there  has  been 
aggravation  of  the  tic  and  incessant  emission  of  laryngeal  sounds  and 
syllables.  Here  then  is  a  parallelism  between  the  two  groups  of  symptoms. 

I  am  disposed,  however,  to  believe  that  the  usual  prognosis  given 
where  motor  and  mental  defects  coexist  is  too  guarded.  I  have  seen  the 
catatonia  of  dementia  praecox  disappear  spontaneously,  in  spite  of  its 
intensity  and  the  unfavourable  outlook  prophesied  by  all  who  had  seen 
the  case. 

In  distinction,  then,  from  the  value  of  a  knowledge 
of  the  patient's  mental  condition,  we  consider  the  motor 
reactions  of  tic  of  little  prognostic  significance. 


CHAPTER    XVIH 

THE    TREATMENT    OF    TICS 

THE  CURABILITY  OF  TICS 

TICS  are  commonly  held  to  be  trivial  affections  of 
but  passing  medical  interest,  while  in  addition 
they  have  gained  the  notoriety  of  being  peculiarly 
rebellious  to  treatment.  Such  undeserved  criticism  is 
at  once  too  superficial  and  too  severe.  As  far  as  life 
is  concerned,  the  prognosis  is  favourable,  but  they 
often  contrive,  quite  as  forcibly  as  many  graver 
diseases,  to  render  existence  intolerable.  To  neglect 
them  or  to  consider  them  a  priori  incurable  is  entirely 
unwarranted.  Some  degree  of  amelioration  is  practi- 
cally always  attainable,  and  even  complete  cures  may 
be  effected. 

It  is  an  old  doctrine  this  of  the  incurability  of  tic, 
but  the  sufferers  have  not  always  been  left  to  their 
fate.  Forecasts  of  methods  of  treatment  likely  to 
ensure  success  were  made  long  ago.  In  the  "  Dictionary 
in  Sixty  Volumes"  of  the  year  1821  will  be  found  a 
definition  of  tic,  a  little  out  of  date  perhaps,  but  afford- 
ing a  glimpse  of  therapeutic  possibilities :  "  The  word 
tic  is  ordinarily  employed  to  designate  certain  unnatural 
habits,  bizarre  attitudes,  peculiar  gestures,  etc.,  whose 
correction  demands  a  painstaking  perseverance  that 
is  not  always  sufficient  to  procure  the  desired  result." 

Trousseau  later  introduced  an  element  of  precision 

398 


THE   TREATMENT  OF  TICS  299 

into  current  therapeutic  measures  by  the  application 
of  a  sort  of  gymnastic  exercise  to  the  muscles  involved. 
He  declared  his  opinion,  however,  that  the  arrest  of 
one  tic  would  soon  be  followed  by  the  development 
of  a  second,  which  would  in  turn  give  place  to  a  third, 
and  so  on ;  for  the  disease  was  essentially  chronic,  and 
in  a  sense  formed  part  of  the  constitution  of  its  subject. 
Subsequent  observation  has  frequently  borne  witness 
to  the  truth  of  this  remark,  though  the  expression  is 
too  absolute. 

For  the  majority  of  the  older  writers,  nevertheless, 
the  incurability  of  tic  was  axiomatic. 

Pujol  held  non-dolorous  facial  tic  to  be  most  intract- 
able. In  the  hands  of  Duchenne  of  Boulogne  faradisa- 
tion of  the  muscles  was  followed  by  only  transient 
improvement.  Axenfeld  considered  idiopathic  facial 
convulsions  hopeless  from  the  point  of  view  of 
treatment. 

It  has  been  remarked  already  that  many  of  the 
earlier  observers  failed  to  discriminate  between  tic  and 
spasm.  In  the  article  "  Face "  in  the  Encyclopedic 
Dictionary,  for  instance,  Troisier  includes  every  sort 
of  facial  movement  under  the  term  "  convulsive  tic," 
among  them  reflex  spasms  from  dental  caries  or  buccal 
ulceration,  and  muscular  contractions  occasioned  by 
peripheral  or  nuclear  irritation.  His  opinions  as  to 
the  curability  or  otherwise  of  these  movements  are 
sufficiently  dogmatic :  "  Convulsive  tic  is  not  a  serious 
condition,  yet  it  is  in  a  majority  of  cases  incurable 
and  as  a  consequence  most  distressing.  One  can  hope 
for  success  only  if  the  tic  is  of  reflex  origin,  where 
extraction  of  a  tooth,  or  local  treatment  of  an  ulcer, 
or  resection  of  part  of  the  trigeminal  nerve  may  be 
indicated." 

Here  the  confusion  is  obvious. 

Gilles  de   la   Tourette's   description   of  the   disease 


300          TICS  AND    THEIR    TREATMENT 

known  as  convulsive  tic  accompanied  with  echolalia  and 
coprolalia  is  couched  in  equally  pessimistic  terms. 

"  It  is  no  menace  to  existence,  and  the  patient  may 
well  attain  a  ripe  old  age,  but  in  revenge  he  stands 
very  little  chance  of  escaping  from  it.  A  radical  cure 
is  yet  to  be  found.  Isolation,  hydrotherapeutics,  elec- 
tricity, and  constitutional  treatment  cannot  do  much 
more  than  retard  its  evolution." 

In  Guinon's  article  on  convulsive  tic  in  the  Encyclo- 
paedic Dictionary  of  the  Medical  Sciences  of  1887  thirty 
pages  were  devoted  to  description  and  the  following  few 
lines  to  treatment: 

This  chapter  will  of  necessity  be  brief.  ...  In  presence  of  this  affection 
the  physician  is  unfortunately  helpless.  During  exacerbations  any  nerve 
sedative  may  be  tried.  In  severe  cases  or  if  the  symptoms  become 
aggravated,  the  sole  treatment  likely  to  be  accompanied  by  improvement, 
scarcely  by  success,  is  a  combination  of  hydrotherapeutics  with  isolation." 

Nor  is  Charcot  much  more  encouraging l : 

We  cannot  say  that  cure  is  certain,  but  we  may  count  on  longer  or 
shorter  intervals  of  arrest,  either  spontaneous  or  as  a  sequel  to  the  employ- 
ment of  serviceable  measures  such  as  hydrotherapy  or  rational  gymnastics. 

It  should  be  said  that  the  cases  which  Charcot, 
Tourette,  and  Guinon  had  more  especially  in  mind  were 
of  a  graver  nature,  such  as  the  disease  of  generalised 
convulsive  tics  with  echolalia  and  coprolalia,  and 
peculiarly  resistant  to  treatment.  Patients  suffering 
from  these  forms  of  tic  present  in  the  most  advanced 
degree  psychical  instability  and  volitional  fickleness, 
and  betray  an  irresistible  tendency  to  impulsion  and 
obsession,  calculated  to  render  the  institution  of  any 
methodical  treatment  futile.  In  their  case  patience 
and  perseverance  may  be  rewarded,  but  they  never 

1  CHARCOT,  Lemons  du  mardi,  \  888-9,  p.  469. 


THE    TREATMENT  OF  TICS  301 

consent  to  undergo  for  a  sufficiently  long  period  the 
discipline  indispensable  for  their  cure. 

Fortunately,  these  severer  varieties  are  exceptional. 
The  vast  majority  of  cases  are  certainly  more  amenable 
to  modern  therapeutic  measures,  and  the  results  obtained 
so  far  place  the  disease  in  a  much  more  favourable  light. 
Letulle  had  already  remarked,  in  1883,  that  the  most 
tenacious  of  co-ordinated  tics  might  be  amended, 
mitigated,  and  even  wholly  inhibited. 

MEDICINAL  TREATMENT 

All  the  ordinary  medicinal  agents  in  vogue  in 
nervous  and  mental  diseases  have  at  one  time  or  other 
been  applied  to  the  cure  of  tics ;  all  have  proved  equally 
inefficacious. 

Sedatives  and  hypnotics,  such  as  the  bromides, 
chloral,  or  the  preparations  of  opium,  sometimes  effect 
a  transient  improvement,  but  they  cannot  permanently 
modify  the  psychasthenia  which  is  the  key  to  the 
situation.  According  to  Grasset  and  Rauzier,  the 
injection  of  morphia,  atropine,  curare,  and  the  inhalation 
of  chloroform  or  ether  have  been  of  some  avail,  as 
has  the  employment  of  zinc  valerianate,  and  of  gelsemium 
in  large  doses.  Quinine,  cannabis  indica,  and  arsenic 
have  also  been  tried. 

Unexpected  success  has  followed  the  administration 
of  the  bromides  in  some  instances,  and  for  the  treatment 
of  various  neuroses,  convulsive  tics  in  particular, 
Flechsig's  opium  and  bromide  cure  for  epilepsy  has 
been  adopted  by  Dornbluth,  with  encouraging  results. 
It  is  true  some  of  the  symptoms  of  epilepsy  may  be 
manifested  in  the  guise  of  tics,  while,  on  the  other  hand, 
the  association  of  tic  and  epilepsy  is  not  unknown ; 
but  however  that  may  be,  there  is  sufficient  and  reliable 
evidence  to  justify  at  least  the  empirical  use  of  bromide 
as  a  last  resource. 


302          TICS  AND   THEIR    TREATMENT 

Every  conceivable  sedative  and  derivative  have  had 
their  advocates,  while  local  and  counter-irritant  medica- 
tion has  not  been  without  support.  Grasset  and  Bauzier 
obtained  transitory  improvement  by  means  of  strong 
mustard  plasters ;  Busch  applied  the  actual  cautery 
to  the  vertebral  column. 

Cold,  hot,  and  tepid  douches,  warm  fomentations, 
simple,  medicinal,  and  vapour  baths,  have  all  been 
prescribed.  Resort  has  been  made  to  rhythmic  traction 
of  the  tongue,  to  thoracic  compression,  to  phrenic 
electrisation,  in  all  of  which  procedures,  as  Oppenheim 
observes,  the  principal  effect  must  be  a  psychical  one. 

The  predisposition  of  the  subjects  of  tic  to  mental 
disturbance  renders  the  administration  of  ether,  morphia, 
or  cocaine  in  their  case  inadvisable.  For  a  similar 
reason  it  is  better  to  avoid  antipyrine,  sulphonal, 
hypnotics  generally,  and  above  all  opium  in  the  form 
of  laudanum  or  thebaic  extract. 

If  a  sedative  be  really  indicated,  we  prefer  the 
preparations  of  valerian,  as  their  disagreeable  odour 
is  scarcely  likely  to  encourage  abuse  of  the  drug. 
Stimulants  such  as  kola,  coca,  caffeine,  etc.,  are  rather 
to  be  avoided.  Hartemberg  recommends  the  prelimin- 
ary use  of  lecithin  to  improve  the  patient's  general 
condition. 

The  inconstancy  of  the  therapeutic  results  hitherto 
obtained  must  not  be  allowed  to  act  as  a  deterrent. 
Success  achieved  by  medicinal  means  may  not  always 
be  attributable  merely  to  suggestion. 

DIET-HYQIENE-HYDROTHERAPY 

The  details  of  the  patient's  diet  are  not  to  be 
neglected  ;  he  may  be  the  victim  of  some  caprice  which 
is  injuring  his  general  health.  In  the  case  of  children 
supervision  is  desirable,  to  obviate  their  eating  either 
too  much  or  too  quickly. 


THE    TREATMENT  OF  TICS  303 

General  hygiene  must  be  made  the  subject  of  special 
attention.  We  have  often  been  convinced  of  the 
salutary  effects  of  alteration  in  a  patient's  mode  of 
life,  or  of  modification  of  his  environment,  such  as  is 
ensured  by  holidaying,  or  by  sea  voyages,  or  by 
"  cures  "  at  watering-places  and  seaside  resorts. 

Hydrotherapy  in  one  or  other  of  its  forms  may  also 
be  utilised.  Except  in  cases  of  hysteria,  the  tepid 
douche  is  preferable  to  the  cold  one.  A  morning  and 
evening  tub,  followed  by  energetic  friction  of  the  skin, 
is  a  favourite  prescription. 

MASSAGE— MECHANOTHERAPY 

In  every  case  of  tic  the  physician  ought  to  assure 
himself  of  the  integrity  of  the  muscles  involved  by 
examining  for  developmental  anomalies,  atrophies, 
hypertrophies,  etc.,  the  presence  of  which  might  lead 
him  to  reconsider  his  diagnosis.  He  may  then  order 
massage,  of  special  value  in  tonic  tics  as  a  prelude  to 
passive  movements,  or  counsel  the  employment  of  some 
form  of  instrument  or  apparatus  to  correct  muscular 
insufficiency  or  to  gauge  the  extent  and  rapidity  of 
motor  reaction. 

As  a  general  rule  we  deprecate  these  devices.  They 
are  open  to  the  same  objections  that  have  been  raised  to 
all  the  mechanical  arrangements  ever  invented  to  counter- 
act stammering,  from  the  pebbles  of  Demosthenes  to 
the  fork  of  Itard,  or  Colombat's  interdental  plate,  or 
Wutzer's  glossonachon,  or  Morin's  marbles  :  the  patient 
is  relieved  of  his  infirmity  only  to  become  the  slave  of 
his  instrument. 

ELECTROTHERAPY 

Electricity  in  all  forms  has  been  requisitioned,  but 
it  does  not  appear  to  have  justified  its  trial.  In  our 


304          TICS  AND   THEIR    TREATMENT 

opinion,  moreover,  it  is  contraindicated   in   convulsive 
affections. 

In  cases  of  functional  spasm  of  the  neck,  Charcot l 
was  wont  to  extol  the  combined  use  of  electricity  and 
massage,  citing  instances  of  a  very  protracted  and 
aggravated  nature  where  relief  or  even  cure  followed 
the  application  of  the  induced  current  to  the  muscles 
not  involved  in  the  spasm. 

A  case  in  point  was  a  man  who  entered  the  Salpetriere  in  1888  with 
clonic  spasm  of  the  sternomastoid  and  trapezius,  originating  in  depression 
caused  by  financial  losses.  The  symptoms  were  not  unlike  what  has 
been  described  more  recently  as  mental  torticollis.  The  condition  had 
resisted  all  treatment  during  nine  months,  but  vanished  with  singular 
rapidity  after  a  few  applications  of  the  battery,  during  which  the  unaffected 
sternomastoid  was  faradised  for  fifteen  minutes  so  as  to  produce  the  inverse 
of  the  pathological  attitude. 

Equally  satisfactory  results  are  frequently  obtained 
in  mental  torticollis  from  the  maintenance  of  the 
antagonistic  position  by  the  hand  or  campimeter,  or 
simply  by  order  given.  It  ought  not  to  be  forgotten, 
however,  that  Charcot  himself  was  astonished  at  these 
unlooked-for  successes,  since  he  closes  his  lesson  with 
the  sceptical  injunction  not  to  hail  the  victory  complete 
nor  ignore  in  such  histories  the  chapter  of  relapses. 

Several  of  our  own  patients,  similarly  affected,  have 
found  electrotherapy  an  egregious  failure.  Most  suf- 
ferers from  tic  have  essayed  it  at  one  time  or  another, 
and  if  they  do  not  accuse  it  of  having  intensified  their 
symptoms,  the  memory  they  retain  of  it  is  usually 
anything  but  pleasant.  All  that  is  permissible  in  suit- 
able cases  is  to  employ  electricity  "in  psychotherapeutic 
doses."  Let  the  patient  see  the  coil,  or  hear  the  inter- 
rupter, or  feel  the  damp  electrodes,  and  even  though 
the  current  be  infinitesimal,  in  the  sequel  the  suggestion 

1  CHARCOT,  Lefons  du  mardi,  June  26  and  July  10,  1888. 


THE   TREATMENT  OF  TICS  305 

may  prove  efficacious.     Generally   speaking,  however, 
such  subterfuges  ought  to  be  avoided. 


SUGGESTION 

Hypnotic  suggestion  has  sometimes  given  tangible 
results,  but  it  is  strictly  applicable  only  to  hysteria, 
which  is,  as  we  have  seen,  a  comparatively  rare  accom- 
paniment of  tic. 

Reference  may  be  made  to  some  cases  of  Raymond 
and  Janet,  where  the  method  was  successful  in  curing 
a  constant  giggle  of  four  months'  duration  ;  hiccough 
also,  and  spasms  of  the  limbs,  were  combated  by  these 
means. 

One  of  the  cases  recorded  by  "Welterstrand l  was  a 
child  of  ten  years  who  had  stammered  ever  since  he 
could  speak  at  all,  and  who  in  addition  had  for  some 
time  suffered  from  facial  contortions — elevation  of  the 
eyelids  and  eyebrows,  and  twitching  of  the  lips.  Six 
seances  sufficed  to  banish  the  symptoms,  which  at  the 
end  of  several  months  had  not  recurred.  Another  of 
his  patients  was  a  young  woman,  twenty  years  old, 
with  incessant  spasmodic  movements  of  mouth  and  eye- 
brows. The  disfiguring  grimaces  of  years  disappeared 
completely  by  the  tenth  sitting. 

Van  Renterghem2  has  recorded  a  case  of  rotatory 
tic  also  cured  by  hypnotism.  Feron  3  and  Vlavianos 4 
report  similar  successes,  but  one  may  legitimately  ask 
whether  the  phenomena  were  not  really  hysterical 

1  WELTERSTRAND,  Uhypnotisme  et  ses  applications  d  la  medecine 
pratique,  Paris,  1899,  pp.  74-6. 

2  VAN  RENTERGHEM,  "  Un  cas  de  tic  rotatoire,"  Journ.  de  neurologic, 
May  20,  1898. 

3  FERON,    "  Un   cas   de  tic  traite  par  la  suggestion,"  Journ.   de 
neurologic,  No.  13,  1899. 

4  VLAVIANOS,   "  Tic  nerveux  traite  avec  succes  par  la  suggestion 
hypnotique,"  Journ.  de  neurologic,  1899,  p.  318. 

20 


306         TICS  AND   THEIR    TREATMENT 

manifestations,  and  if  the  results  attained  any  degree  of 
permanence.  Treatment  by  suggestion  is,  as  a  general 
rule,  ineffectual.  In  Marechal's 1  case  of  mental  torticollis 
with  symptoms  of  two  years'  duration,  recourse  was 
made  to  this  measure  but  without  avail,  and  our  ex- 
perience has  been  identical. 

Raymond  and  Janet 2  have  noted  favourable  results 
by  the  adoption  of  suggestion  during  waking  hours, 
without  going  the  length  of  hypnotic  sleep;  in  one 
case  of  tic  simulating  chorea,  a  cure  followed  the  threat 
of  surgical  intervention. 

The  same  objection  may  be  raised  to  ordinary  as  to 
hypnotic  suggestion,  that  it  is  not  of  universal  applica- 
bility. Besides,  it  is  very  difficult  to  know  exactly 
what  meaning  the  term  is  intended  to  convey.  To  en- 
courage the  patient  and  assure  him  of  progress,  to 
reproach  or  reprimand  him  on  occasion,  is  to  employ 
an  integral  and  invaluable  factor  in  all  re-educational 
treatment  of  tics ;  but  is  this  truly  suggestion  ? 

SURGICAL  TREATMENT 

Surgical  procedures  are  and  can  be  applicable  only 
to  a  small  minority  of  tics,  principally  those  of  the  neck, 
and  in  particular  mental  torticollis. 

Now,  while  we  question  the  necessity  of  emphasising 
afresh  the  uselessness  of  surgical  interference,  we  believe 
it  incumbent  on  us  to  indicate  more  precisely  the  ex- 
treme, inefficacious,  and  sometimes  perilous  nature  of 
the  measures  to  which  patients  are  exposed  in  the  vain 
hope  of  putting  an  end  to  their  mal  obs&dant. 

In  the  vast  majority  of  cases  .the  upshot  of  operative 
intervention  is  the  creation  of  transient  or  permanent 

1  MARECHAL,  "  Un  cas  de  torticolis  spasmodique,"  Joum.  de 
neurologic,  May  20,  1899. 

1  RAYMOND  AND  JANET,  Neuroses  et  idles  fixes,  vol.  ii. 


THE   TREATMENT  OF  TICS  307 

muscular  paralyses  and  pareses.  Of  two  infirmities 
patients  voluntarily  choose  the  one  whose  evils  have 
not  yet  been  brought  home  to  them.  To  enlighten 
them,  to  warn  them  against  their  own  rashness,  to 
impress  on  them  repeatedly  the  truth  of  the  fact  that 
so-called  radical  operations  do  not  exclude  the  possibility 
of  recurrence — this  we  conceive  to  be  our  bounden  duty. 

Spasmodic  torticollis  more  particularly  has  tested 
the  surgeon's  sagacity  and  talent.  Yet  in  the  ever- 
increasing  number  of  recorded  cases  there  is  usually 
a  curious  indefiniteness  of  statement  on  a  point  of 
primary  importance  :  was  surgical  aid  sought  for  the 
treatment  of  a  tic,  or  of  a  spasm  ? 

Torticollis  tic — mental  torticollis — is  a  psychical 
disease  pure  and  simple,  which  does  not  enter  the  pro- 
vince of  surgery,  while  torticollis  spasm — spasmodic 
wryneck — may  come  within  the  scope  of  the  surgeon's 
knife,  though  only  on  condition  that  the  irritative 
lesion  be  sharply  localised.  Now,  not  only  is  this 
information  generally  missing,  but  even  more  frequently 
perhaps  a  hard  and  fast  line  between  the  two  cannot 
be  drawn.  The  wisest  course  would  be  to  delay  the 
adoption  of  a  plan  of  treatment  whose  results  are 
so  problematical,  but  these  considerations  have  un- 
fortunately been  outweighed  by  the  operator's  laudable 
desire  and  expectation  of  ensuring  respite  from  a  most 
painful  affliction. 

It  is  purposely  to  demonstrate  how  invalid  this  plea 
must  henceforth  remain  that  we  shall  now  pass  rapidly 
in  review  the  various  surgical  devices  imagined  for  the 
relief  of  torticollis  tics  and  spasms. 

The  first  methods  to  be  practised  were  elongation, 
ligature  (Collier),  section  (Gardner  and  Giles),  or  re- 
section, of  the  spinal  accessory.  The  last  of  these  was 
performed  for  the  first  time  by  Campbell  in  1866,  then 
by  Southam,  Mayor,  Collier,  Pearce  Gould,  Edmond 


308         TICS  AND   THEIR   TREATMENT 

Oxen,  Appleyard,  Atkins,  etc.  Eliot  *  was  convinced 
of  the  value  of  this  measure,  and  made  a  special 
study  of  the  technique.  Coudray2  recognised  the  in- 
sufficiency of  section  or  resection  of  the  accessory,  yet 
decided  in  its  favour. 

In  the  present  state  of  our  knowledge  (he  says),  the  treatment  to  be 
preferred  for  spasmodic  torticollis  is  resection  of  the  external  branch  of 
the  accessory.  Its  superiority  over  the  multiple  and  successive  divisions 
of  the  neck  muscles  vaunted  by  Kocher — apart  from  the  absence  of  proof 
that  the  latter  is  more  efficacious  than  the  simpler  operation — is  based  on 
the  view  that,  as  the  dependence  of  the  condition  on  cerebral  lesions  and 
its  occurrence  in  nervous  individuals  render  uncertain  the  accomplishment 
of  a  complete  cure  in  every  instance,  with  such  a  class  of  patient  it  is 
essential  to  have  recourse  to  an  operative  minimum.  In  nearly  every 
case,  nevertheless,  marked  amelioration  ensues  on  this  procedure,  the 
benefit  derived  from  it  forming  its  thorough  justification. 

If  the  advantages  of  such  an  operation  are  not  more 
appreciable,  we  must  take  up  a  position  of  much  greater 
reserve  regarding  its  suitability,  particularly  in  view  of 
the  fact  that  the  prosecution  of  a  line  of  treatment 
absolutely  devoid  of  risk  may  assure  equally,  if  not 
more,  satisfactory  results. 

The  next  step  was  to  devote  attention  to  the  cervical 
nerves. 

The  co-existence  of  goitre  and  functional  spasm  of 
the  neck  suggested  to  Pauly 3  that  pressure  on  the  re- 
current laryngeal  nerve  might  occasion  a  reflex  spasm 
via  the  muscular  branch  of  the  spinal  accessory.  By 
analogy,  in  some  cases  of  spasmodic  torticollis  a  point 
of  irritation  on  one  of  the  sensory  nerves  of  the  cervical 

1  ELIOT,  "  The  Surgical  Treatment  of  Torticollis,  with  Special 
Reference  to  the  Spinal  Accessory  Nerve,"  Annals  of  Surgery,  1895, 

P-  493- 

1  COUDRAY,  "  Torticolis  spasmodique,  resection  du  spinal,"  Associa- 
tion franfaise  de  chirurgte,  October,  1898. 

3  PAULY,  "Spasmes  fonctionnels  du  cou,"  Congres  franfais  de 
medecine  interne,  Lyon,  October,  1894. 


THE    TREATMENT  OF  TICS  309 

plexus  might  generate  a  reflex  motor  reaction  in  the 
area  of  the  accessory,  with  possible  diffusion  to 
neighbouring  trunks.1  It  might  then  be  a  good  plan 
to  divide  the  branches  of  the  superficial  cervical  plexus, 
just  as  the  trigeminal  is  divided  for  tic  douloureux  of 
the  face. 

It  soon  became  obvious  that  resection  of  the  spinal 
accessory  was  insufficient.  Bisien  Russell2  adduced 
physiological  evidence  to  show  that  some  of  the  muscular 
groups  involved  in  the  condition  are  not  innervated 
by  the  spinal  accessory,  but  by  the  second,  third,  and 
fourth  cervical  roots,  section  of  which  is  imperative  to 
obtain  positive  results. 

The  surgeon  had  not  been  behindhand,  however. 
Gardner  in  1888  was  convinced  of  the  necessity  of 
dealing  with  the  posterior  branches  of  the  second  and 
third  cervical  pairs,  a  method  practised  a  few  months 
later  by  Smith  and  by  Keen.  One  or  two  cases  recorded 
by  Ballance,  according  to  whom  division  of  the  posterior 
roots  was  performed  as  far  back  as  1882  or  1883,  are 
highly  instructive : 

A  woman,  thirty-two  years  old,  had  suffered  for  seventeen  months 
from  convulsive  movements  inclining  the  head  to  the  right  shoulder  and 
turning  the  face  to  the  left,  the  muscles  affected  being  the  sternomastoids, 
right  trapezius,  and  complexus.  On  May  30,  1887,  half  an  inch  of  the 
left  spinal  accessory  was  resected  before  its  entry  into  the  muscle,  whereupon 
the  spasm  diminished  in  intensity  and  the  sternomastoids  ceased  to 
contract.  On  June  6  two-thirds  of  an  inch  of  the  right  accessory  was 
removed,  the  patient  being  able  four  days  later  to  keep  her  head  straight 
by  the  application  of  her  hand  to  the  right  side  ;  but  on  July  4  violent 
spasms  of  the  trapezius  recommenced,  demanding  section  of  the  posterior 
branch  of  the  second  pair.  By  the  zist  there  was  a  little  stiffness  of 
the  neck  on  the  right  which  speedily  disappeared,  and  in  March,  1891, 
recovery  was  still  complete. 

1  PAULY,  "Th6orie  reflexe  du  torticolis  spasmodique,"  Revue  de 
medectne,  1897,  p.  130. 

*  RISIEN  RUSSELL,  Brain,  1897,  p.  35. 


3io         TICS  AND   THEIR   TREATMENT 

The  second  case  concerned  a  woman,  aged  twenty-nine,  with  con- 
vulsive movements  of  the  trapezii  dating  back  seven  years.  Resection  of 
both  spinal  accessory  nerves  at  the  posterior  border  of  the  sternomastoid 
was  practised  on  November  21,  1892  ;  consecutive  double  trapezius 
paralysis  revealed  the  fact  that  the  deep  rotators  of  the  head  on  either  side 
were  similarly  in  a  state  of  spasm  ;  on  December  13,  1892,  the  posterior 
branches  of  the  first,  second,  and  third  left  cervical  roots  were  divided  by 
Keen's  method,  the  contractions  being  now  confined  to  the  deep  rotators 
of  the  right  side,  which  were  to  be  treated  in  their  turn  in  the  same 
manner. 

Comment  is  needless. 

In  a  case  of  spasm  of  the  left  sternomastoid  and 
certain  muscles  of  the  neck  reported  by  Chipault,1 
bilateral  removal  of  the  superior  cervical  sympathetic 
ganglion  was  followed  by  instantaneous  relief,  succeeded 
by  a  relapse  and  a  second  cure ;  a  degree  of  retrocollic 
spasm  persisted. 

Kocher's  plan  of  cutting  successively  all  the  muscles 
affected  has  given  varying  results,  according  to  de 
Quervain.  This  procedure  has  been  adopted  by  others, 
notably  by  Nove-Josserand 2  in  a  case  where  treatment 
by  suggestion  had  proved  of  no  avail.  For  some  days 
after  the  operation  the  spasm  was  exaggerated,  although 
it  eventually  disappeared. 

It  is  permissible,  however,  to  doubt  the  definite  and 
radical  nature  of  these  cures  if  we  look  at  the  long 
catalogue  of  admitted  operative  failures. 

Linz's  two  cases  3  of  resection  were  unsatisfactory. 
In  Popoff  's  experience 4  tonic  muscular  spasm  returned 
in  spite  of  repeated  neurectomies,  in  contradistinction  to 
the  notable  improvement  he  accomplished  by  simple 

1  CHIPAULT,  Travaux  de  neurologic  chirurgicale,  1901,  p.  220. 

*  NOVE-JOSSERAND,  "  Sur  un  cas  de  torticolis  spasmodique,"  Lyon 
medical,  September  4,  1898. 

1  LINZ,  "  Ueber  spastische  Torticollis,"  Inaug.  Dissert.,  Bonn,  1897. 

4  POPOFF,  "Torticolis  spastique,  torticolis  mental  (Brissaud), 
torticolis  psychique  ou  polygonal,"  Moniteur  russe  de  neurologic, 
1899,  No.  4. 


THE    TREATMENT  OF  TICS  311 

re-education.  Tichoff1  found  the  torticollis  reappear 
four  days  after  division  of  the  spinal  accessory,  and 
though,  in  his  opinion,  relapse  supervenes  after  this 
operation  in  more  than  fifty  per  cent,  of  cases,  he  ex- 
presses himself  in  favour  of  further  operative  inter- 
ference. 

Two  of  Dalwig's  patients  developed  a  functional 
torticollis  to  avoid  the  diplopia  caused  by  a  superior 
strabismus.  Ocular  tenotomy,  as  might  have  been 
foreseen,  was  quite  ineffectual  in  checking  the  tic ; 
indeed,  the  author  himself  seems  to  have  been  well 
aware  of  the  necessity,  in  curing  such  vicious  habits,  of 
influencing  the  attention.  He  proceeds  to  emphasise 
the  hopefulness  of  orthopaedic,  as  opposed  to  surgical, 
treatment,  and  recommends  the  use  of  a  cardboard 
collar,  though  any  benefit  thus  derived  is,  in  our 
experience,  purely  ephemeral. 

A  case  of  Oppenheim's  underwent  first  tenotomy, 
then  elongation,  and  finally  resection  of  the  spinal 
accessory,  with  the  result  that,  in  spite  of  complete 
atrophy  of  the  sternomastoid  and  partial  atrophy  of 
the  trapezius,  spasm  settled  with  renewed  intensity  on 
the  splenius,  omohyoid,  and  remaining  fibres  of  the 
trapezius.  Application  of  a  seton  was  equally  negative, 
but  the  patient  soon  after  made  astonishing  improvement 
by  a  mineral  water  "  cure  "  ! 

In  face  of  such  facts,  it  is  truly  surprising  to  see 
the  increasing  support  given  to  surgical  intervention. 
"Walton,2  for  an  instance,  admits  the  central  origin  and 
progressive  nature  of  the  disease,  and  recognises  the 
futility  of  surgical  procedures,  yet  constitutes  himself 

1  TICHOFF,  "  Un  cas  de  convulsions  toniques  et  cloniques  des 
muscles  du  cou,"  Soc.  de  neur.  et  de  psychiat.  de  Kazan,  March  26  and 
September  24,  1895. 

1  WALTON,  "Nature  and  Treatment  of  Spasmodic  Torticollis," 
Amer.Joum.  of  the  Med.  Sc.,  March,  1898,  p.  295. 


312         TICS  AND   THEIR   TREATMENT 

their  advocate.     Would  it  not  be  more  in  accordance 
with  the  dictates  of  reason  and  wisdom  to  refrain  ? 

"We  must  not  omit  to  mention  the  extraordinary 
method  devised  by  Corning1  of  injecting  into  the 
muscles  a  warm  mixture  of  tallow  and  oil  which  will 
solidify  at  37°  C.,  to  which  proceeding  he  proposes  to 
give  the  fantastic  name  of  elceomyenchisia.  The  idea  is 
to  fix  previously  relaxed  muscles.  He  does  not  seem  to 
have  had  many  imitators. 

Torticollis  apart,  few  tics  invite  treatment  at  the 
hands  of  the  surgeon,  with  the  exception  of  facial  tics 
or  spasms. 

Here,  too,  the  results  have  usually  been  anything  but 
encouraging.  Stewens 2  reports  three  cases  of  facial 
tic  cured  by  the  correction  of  errors  of  refraction,  while 
elongation  of  the  facial  nerve  failed  of  its  object. 
Resection  of  a  branch  of  the  trigeminal  is  valueless ; 
facial  elongation  only  causes  a  corresponding  paralysis, 
and  should  this  latter  accident  be  transient,  as  in  a  case 
of  Bernhardt's,  so  is  the  relief  from  the  tic. 

To  obviate  the  much  more  frequent  inconvenience 
of  a  permanent  facial  paralysis,  J.  L.  Faure  3  suggests 
spino-facial  anastomosis.  In  a  woman  suffering  from 
contracture  and  spasmodic  twitchings  in  the  region  of 
the  facial,  Kennedy,  of  Glasgow,  divided  the  nerve  and 
immediately  anastomosed  the  cut  end  laterally  with  the 
spinal  accessory.  At  the  end  of  fifteen  months  the 
spasm  had  vanished  and  the  paralysed  facial  nerve  had 
recovered  its  functions.4 

1  CORNING,  "  Elceomyenchisis,  or  the  Treatment  of  Chronic  Local 
Spasm   by  the  Injection   and   Congelation    of    Oils  in  the    Affected 
Muscles,"  New  York  Medical  Journal,  1894,  p.  449. 

2  STEWENS,  "  Facial  Spasm  and  its  Relation  to  Errors  of  Refrac- 
tion," Amer.  Journ.  of  the  Med.  Sc.,  1900,  p.  33. 

8  FAURE,  "  Traitement  de  la  paralysie  faciale  d'origine  traumatique 
par  1'anastomose  spino-faciale,"  Presse  medicalet  1901,  p.  259. 
*  See  BREAVOINE,  These  de  Paris,  1901. 


THE    TREATMENT  OF  TICS  313 

Strictly  speaking,  then,  in  certain  cases  of  genuine 
facial  spasm  the  possibility  of  some  such  treatment  may 
be  entertained  if  all  other  means  have  failed,  but  per- 
sistence of  the  facial  palsy  and  the  grave  consequences 
it  may  entail  are  always  to  be  dreaded.  In  facial  tics, 
however,  under  no  pretext  whatever  is  the  surgeon 
justified  in  attempting  to  interfere. 

In  the  case  of  spasms  properly  so  called,  efforts  directed 
to  the  removal  of  the  exciting  cause — should  it  be  known 
— are  often  crowned  with  success.  Conjunctivitis, 
rhinitis,  odontalgia,  may  occasion  grimaces  and  contor- 
tions which  cease  with  the  disappearance  of  the  irrita- 
tion. In  1884  Fraenkel  showed  to  the  Medical  Society 
of  Berlin  a  woman,  forty-five  years  old,  with  mimic 
convulsions  of  four  years'  duration,  attributable  to  a 
rhinitis.  Every  time  the  mucous  membrane  of  the  left 
nasal  fossa  was  touched  a  violent  spasm  ensued ;  but  a 
few  applications  of  .the  galvano-cautery  brought  the 
phenomena  to  an  end. 

Oppenheim  has  seen  facial  and  masseter  spasm 
checked  by  the  extraction  of  a  carious  tooth,  and  in 
another  case  by  an  operation  on  the  ear. 

Emphasis  must  once  more  be  laid  on  the  fact  that 
any  success  achieved  has  been  in  reference  to  spasms  ; 
as  much  cannot  be  said  of  tics  and  analogous  affections. 
The  surgical  treatment  of  stammering  has  long  since 
received  its  quietus. 

"We  may  bring  this  discussion  to  a  close  by  applying 
to  tics  in  general  certain  considerations  of  Brissaud l 
anent  mental  torticollis  : 

"  Instead  of  proceeding  to  operate  at  once  and  being 
content  thereafter  to  enjoin  on  the  patient,  whenever 
the  wound  is  healed,  a  course  of  exercises  to  be  per- 
severed with  over  long  months  or  even  years,  better 

1  BRISSAUD,  Revue  neurologtque,  1897,  p.  34. 


314         TICS  AND   THEIR    TREATMENT 

give  the  same  good  advice  long  months  or  even  years 
before  inflicting  him  with  the  operation." 

ORTHOP/EDIC    TREATMENT 

The  use  which  has  in  some  instances  been  made 
of  various  forms  of  apparatus  for  temporary  fixation  or 
for  gymnastic  purposes  is,  as  a  rule,  rather  hurtful  than 
otherwise.  The  patient  is  disconcerted  by  their  with- 
drawal, and  prone  to  recommence  his  inopportune 
movements.  It  is  preferable  to  allow  him  to  adopt  his 
own  attitudes  independently  of  the  physician.  An 
accessory  not  always  at  hand  must  not  be  allowed  to 
become  indispensable  to  the  control  of  his  tic,  else  he 
may  make  its  absence  a  pretext  for  the  discontinuation 
of  his  exercises. 

Excellent  results,  it  is  true,  have  been  obtained  in 
chorea  by  recourse  to  apparatus  of  restraint.  According 
to  the  recent  descriptions  of  Huyghe  l  and  of  Verlaine,8 
after  the  administration  of  a  few  whiffs  of  chloroform 
to  the  patient,  the  affected  limbs  are  massaged  vigor- 
ously enough  to  enable  him  to  have  some  conception 
of  what  is  being  done.  Light  anaesthesia  is  continued 
while  they  are  immobilised  in  duly  padded  splints  and 
covered  closely  with  bandages.  At  the  end  of  five  or 
six  days  the  dressings  are  removed,  when  all  choreic 
twitching  will  be  found,  as  a  general  rule,  to  be  gone ; 
should  it  persist,  the  treatment  must  be  repeated.  In 
numerous  instances  the  method  has  been  eminently 
successful. 

So  favourable  an  issue  is  scarcely  to  be  looked  for 
in  the  case  of  tics.  Rather  are  these  forms  of  apparatus 
liable  to  do  harm  in  the  direction  of  fresh  outbursts. 

1  HUYGHE,  "  Du  traitement  de  la  chor6e  hyst6rique  par  1'immo- 
bilisation,"  Le  nord  medical,  August  I,  1901. 

1  VERLAINE,  "  Traitement  de  la  choree  arythmique  hysterique  par 
1'im mobilisation  sous  chloro forme,"  These  de  Lille,  1901. 


CHAPTER    XIX 

TREATMENT    BY   RE-EDUCATION 

author  of  the  article  "  Tic "  in  the  Dictionary 
-L  in  Sixty  Volumes  of  1822  urges  the  necessity 
of  care  and  perseverance  in  the  correction  of  the 
involuntary  movements  characteristic  of  the  disease. 
In  1830  Jolly  recommended  different  exercises  in  the 
treatment  of  convulsions,  as  a  means  of  interrupting  the 
sequence  of  certain  spasmodic  phenomena.  Blache's  l 
adoption,  in  1851,  of  medical  gymnastics  in  cases  of 
"  abnormal  chorea  "  was  attended  with  excellent  results ; 
and  Trousseau,  as  we  have  seen,  extolled  the  value 
of  exercises  systematically  applied  to  the  muscles 
involved  in  non-dolorous  tic.  The  principle  of  the 
treatment  consisted  in  the  regular  execution  of  given 
movements  by  the  muscular  groups  affected,  to  the 
rhythmical  accompaniment  of  a  metronome  or  the 
pendulum  of  a  clock. 

In  these  instances  we  have  a  forecast  of  the  modern 
methods  of  re-education,  so  successfully  employed  to 
combat  tic. 

Letulle  advises  an  appeal  to  the  intelligence,  good 
sense,  and  will  of  the  patient  in  the  endeavour  to  pro- 
voke an  inverse  effort  at  the  moment  when  the  tic  begins, 
or  even  before.  It  is  the  prerogative  of  the  physician 
to  indicate  suitable  exercises  and  to  encourage  and  aid 

1  BLACHE,  "Traitement  de  la  choree  infantile,"  Gazette  hebdoma- 
daire,  1864,  p.  787. 


316         TICS  AND   THEIR   TREATMENT 

the  patient  in  his  attempts.  Even  the  most  inveterate 
of  tics  may  thus  be  controlled  and  made  to  disappear. 
On  the  other  hand,  the  TraiU  de  mtdecine  ignores  the 
subject,  while  Lannois'  paper  in  the  Traite  de  therapeu- 
tique  contains  the  statement  that  in  the  treatment 
of  myoclonus — under  which  term  various  indefinite 
convulsive  movements  are  comprehended — no  method 
has  hitherto  been  of  any  avail.  Yet  in  another  section 
of  the  same  book  we  discover  some  sound  advice  anent 
tics  and  choreas  of  hysterical  origin,  emanating  from 
the  pen  of  Pierre  Janet. 

It  is  well  to  study  the  influence  of  the  attention  on  these  conditions  ; 
some  tics  are  contingent  on  the  direction  of  the  patient's  attention  to  them, 
others  appear  solely  during  times  of  distraction.  .  .  .  Education  of 
movements  by  some  form  of  drill  may  be  of  the  greatest  utility. 

These  general  therapeutic  indications  are  applicable 
to  all  kinds  of  tic,  independently  of  their  form  and 
localisation.  Moreover,  they  conform  to  the  procedures 
advocated  by  Brissaud  since  1893. 

So  long  as  tic  is  regarded  as  a  purely  external  phe- 
nomenon, treatment  is  bound  to  be  insufficient;  but 
recognition  of  the  relations  between  the  convulsion  and 
the  mental  state  of  the  subject  has  made  possible  a  rational 
therapeusis.  There  can  be  no  doubt,  thanks  to  the 
laborious  work  of  Bourneville,  that  systematised  mental 
discipline  has  sometimes  a  surprising  effect  on  congenital 
psychical  imperfections;  and  where  the  patients  have 
attained  a  higher  level  of  mental  development,  re- 
education has  shown  itself  to  be  the  method  par 
excellence. 

The  credit  of  initiating  treatment  by  forced  im- 
mobility is  due  to  Brissaud,  who  in  the  year  1893 
first  utilised  the  method  in  cases  of  mental  torticollis. 
In  the  face  of  the  risks  of  surgical  intervention  and 
the  unsatisfactory  nature  of  existing  therapeutic 
measures,  Brissaud  emphasised  the  value  of  motor 


TREATMENT  BY  RE-EDUCATION       317 

discipline  in  tic,1  and  it  was  not  long  ere  rules  were 
formulated  and  precision  introduced  into  the  applica- 
tion of  the  method.2  The  results  were  certainly 
encouraging,  so  much  so  that  improvement  could  be 
promised  if  treatment  was  sufficiently  protracted ;  cure, 
indeed,  followed  in  various  instances. 

Brissaud's  method  is  a  combination  of  immobilisation 
of  movements  with  movements  of  immobilisation. 
Speaking  generally,  the  patient  is  directed  to  perform 
certain  appropriate  exercises  under  given  conditions. 
Some  of  these  exercises  are  intended  to  teach  him  how 
to  preserve  immobility,  while  the  object  of  others  is 
to  replace  an  incorrect  movement  by  a  normal  one.  In 
the  case  of  the  former,  immobility  is  alike  the  goal  in 
view  and  the  means  of  attaining  it,  while  by  recourse 
to  suitable  movements,  in  the  latter  instance,  the  same 
end  is  sought. 

It  is  essential  to  remember  that  the  exercises  must 
be  graduated.  To  begin  with,  the  subject  of  tic  is 
required  to  remain  absolutely  motionless,  as  for  a 
photograph,  for  one,  two,  three  seconds — in  fact,  as 
long  as  he  can  without  fatigue.  Very  gradually  the 
period  is  increased,  for  patients  have  their  good  and 
their  bad  days,  and  too  great  a  demand  on  one  day  is 
apt  to  be  succeeded  by  a  relapse  on  the  next.  One  must 

1  BRISSAUD,  "Tics  et  spasmes  cloniques  de  la  face,"  Journ.  de 
medecine  et  de  chirurgie  pratiques,  January  25,  1894.  BRISSAUD  AND 
MEIGE,  "  Trois  nouveaux  cas  de  torticolis  mental,"  Rev.  neur., 
December  10,  1894,  p.  697.  BOMPAIRE,  "Du  torticolis  mental,"  These 
de  Paris,  1894.  FEINDEL,  "  Le  traitement  medical  du  torticolis 
mental,''  Nouv.  icon,  de  la  Salpetriere,  1894,  p.  404.  Id.,  "Le  torti- 
colis mental  et  son  traitement,"  Gazette  hebdomadaire,  February  20, 
1898,  p.  169.  FEINDEL  AND  MEIGE,  "  Revision  iconographique  du 
torticolis  mental ;  cas  anciens  et  cas  nouveaux  ;  traitement,"  Congres  de 
Paris,  1900,  volume  de  la  section  de  neurologie,  p.  513.  Id.,  "Quatre 
cas  de  torticolis  mental,"  Arch.  gen.  de  medecine,  January,  1901,  p.  61. 

3  BRISSAUD  AND  FEINDEL,  "  Sur  le  traitement  du  torticolis  mental  et 
des  tics  similaires,"  Journal  de  neurologie,  April  15,  1899. 


3i 8          TICS  AND   THEIR   TREATMENT 

rest  content  with  even  the  most  insignificant  gain  at 
first,  and  soon  the  seconds  will  grow  into  minutes,  and 
the  minutes  into  hours.  It  is  desirable  to  specify  on 
each  occasion  the  duration  of  the  expected  immobility. 
Place  the  patient  at  the  outset  in  the  position  in  which 
his  tic  manifests  itself  least  often,  and  do  not  cease 
to  encourage  him  by  affirming  that  he  can  and  must 
remain  immobile.  Once  the  seance  of  immobilisation 
can  be  maintained  for  as  much  as  five  or  six  minutes, 
begin  to  modify  the  patient's  attitudes.  If  he  has  been 
comfortably  seated  during  the  opening  performances, 
try  him  when  he  is  standing,  and  as  soon  as  he  has 
accomplished  this,  vary  the  position  of  his  head,  arms, 
trunk,  and  legs,  repeating  the  seance  in  each  case. 
Eventually  he  will  learn  to  maintain  immobility  of 
certain  parts  of  his  body  while  he  is  walking,  or  while 
he  is  executing  given  movements  with  his  arms  or 
legs.  In  all  these  performances  direction  must  be 
specially  directed  to  the  patient's  tic.  The  method 
is  obviously  simple,  so  much  so  that  he  may  be  inclined 
to  question  its  utility  and  may  fail  to  grasp  its  import. 
One  must  not  hesitate,  however,  to  explain  its  purpose ; 
indeed,  the  rapid  and  intelligent  appreciation  of  the 
method  on  the  part  of  the  patient  is  a  sine  qua  non  for 
success.  Patient  and  doctor  must  co-operate  in  defence 
and  attack ;  and  their  union  will  culminate  in  triumph. 
Simultaneously  with  this  discipline  of  immobilisation 
the  subject  must  be  taught  the  discipline  of  movements. 
The  idea  is  to  make  him  perform  slow,  regular,  and 
accurate  movements  to  order,  addressing  oneself  to  the 
muscles  of  the  area  in  which  the  tic  is  localised.  They 
must  be  very  simple  at  first,  and  the  exercises  must 
be  very  short.  The  stance  should  never  be  prolonged 
beyond  a  few  minutes,  making,  with  the  immobilisation, 
not  more  than  half  an  hour.  This  time  will,  of  course, 
soon  be  increased,  but  it  is  of  prime  importance  to 


TREATMENT  BY  RE-EDUCATION       319 

avoid  fatigue.  The  performances  should  be  gone 
through  three,  four,  or  five  times  a  day,  and  always  at 
the  same  hours.  One  of  them  at  least  ought  to  be 
under  the  personal  direction  of  the  physician,  whose 
duty  it  is  to  modify,  instruct,  exhort,  reprimand,  as 
the  case  may  be.  In  his  absence  the  supervision  of 
the  exercises  must  be  left  to  some  responsible  individual, 
who  has  an  eye  for  faults  as  well  as  for  progress. 
Statements  by  the  patients  themselves  are  to  be  con- 
sidered with  reserve. 

The  repetition  of  the  prescribed  exercises  should 
take  place  in  front  of  a  looking-glass,  whereby  the 
patient  may  be  exactly  informed  of  any  mistakes  in 
gesture  or  attitude.  He  cannot  otherwise  judge  of  the 
degree  of  immobility  attained,  and  may  deceive  himself, 
although  he  has  the  best  intentions  in  the  world,  as 
to  the  real  state  of  affairs.  He  does  not  know  whether 
he  is  holding  himself  straight  or  not,  as  a  general  rule, 
but  a  glance  in  the  mirror  will  correct  his  fault.  A 
careful  register  must  be  kept  of  the  progress  he  makes. 
Little  by  little  the  jurisdiction  of  the  physician  will 
be  reduced,  provided  the  patient  maintains  his  interest 
in  his  own  treatment.  Indifference  and  discouragement 
are  fatal,  and  it  must  be  the  physician's  aim  to  prevent 
their  occurrence. 

Seglas  has  reported  the  history  of  a  woman  with 
mental  torticollis,  who  submitted  to  treatment  by 
Brissaud's  method,  and  a  remarkably  quick  alleviation 
was  the  result.  At  the  end  of  three  weeks,  however, 
she  allowed  her  interest  to  slacken,  and  ere  long  the 
benefits  obtained  were  entirely  frustrated. 

It  cannot  be  too  often  repeated  that  even  though 
the  tic  disappear,  the  patient  must  not  be  abandoned 
to  himself,  but  must  be  persuaded  to  continue  his 
exercises.  This  is  the  price  of  success.  As  time  goes 
on,  it  is  true,  he  encounters  fewer  difficulties  in  his 


320         TICS  AND   THEIR   TREATMENT 

way,  and  once  he  is  conversant  with  the  method,  he 
may  be  able  to  work  out  his  own  salvation. 

In  the  case  of  children,  the  efforts  of  the  medical 
man  may  often  be  seconded  by  parent  or  teacher,  who 
has  assisted  at  the  first  lessons  and  is  in  a  position 
to  superintend  their  repetition.  On  the  other  hand, 
treatment  may  be  nullified  by  deplorable  weakness  on 
the  part  of  father  or  mother.  One  of  the  reasons  for 
the  existence  or  at  least  the  persistence  of  tics  in 
children  is  that  there  has  been  no  attempt  at  their 
correction  when  they  were  still  "  bad  habits."  Neglect 
or  indulgence  is  an  etiological  factor  of  the  first 
importance,  as  we  have  already  seen.  Many  a  time 
we  have  had  occasion  to  note  this,  notwithstanding 
the  protestations  of  the  family.  Fear  of  aggravating 
the  mischief  is  sometimes  advanced  as  a  reason  for 
non-interference.  Nothing  could  be  more  misleading. 

The  method  which  seeks  to  check  the  youthful 
liqueur  by  the  multiplication  of  threats  and  penalties 
is  not  to  be  countenanced;  it  produces  the  opposite 
effect  to  what  is  intended.  Clearly  the  educational 
therapeutic  measures  we  have  been  advocating  demand 
a  patience  and  an  ingenuity  on  the  part  of  both  doctor 
and  patient  which  we  have  no  desire  to  minimise,  but 
it  is  along  these  lines  that  success  is  to  be  reached. 

A  noteworthy  adjunct  to  treatment  is  to  sketch  out 
a  daily  routine  for  the  patient  to  follow  regularly  and 
punctually.  His  mental  disarray  is  patent  not  merely 
from  his  disorders  of  motility,  but  in  the  unmethodical 
and  changeable  habits  of  his  everyday  life.  To  in- 
troduce discipline  into  his  manner  of  living  is  a  most 
wholesome  step.  To  find  something  with  which  to 
employ  his  leisure  time,  to  direct  his  energies  into 
suitable  channels,  will  prove  to  be  eminently  beneficial, 
not  merely  for  the  child  but  also  for  the  adult.  Those 
who  tic  ought  to  be  able  to  contract  good  habits  as 


TREATMENT  BY  RE-EDUCATION       321 

readily  as  bad,  provided  their  instructor  be  sufficiently 
persevering  and  inventive. 

There  is  an  infinity  of  occupations  for  the  patient 
to  put  his  hands  to,  and  this  variety  suits  his  unsettled 
mood  and  his  wavering  attention ;  but  longer  efforts 
will  be  secured  from  him  if  his  interest  in  his  task 
can  be  engaged  and  stimulated  as  well.  It  is  a  good 
plan  to  make  him  write  down  each  day  what  he  does 
and  how  it  is  done,  and  to  have  him  rehearse  from 
time  to  time.  Such  pedagogical  details  are  far  from 
being  superfluous ;  adults,  moreover,  are  quick  to  gather 
their  significance  and  to  demonstrate  their  advantages 
in  practice.  That  their  fickle  will  must  be  reinforced 
they  know  well ;  how  to  achieve  this  end  they  are 
unaware.  This  fact  explains  their  eager  acceptance  of 
the  support  furnished  by  these  "  moral  crutches." 

Generally  speaking,  there  is  no  call  to  interrupt 
treatment  once  it  is  commenced,  although  occasionally 
we  have  found  this  desirable.  The  fatigue  of  the  first 
few  days,  almost  unavoidable  as  it  is,  and  accompanied 
by  new  sensations,  need  occasion  no  alarm.  We  should 
acquaint  our  patient  of  its  explanation,  and  so  obviate 
the  mental  depression  which  its  existence  is  apt  to 
engender.  Its  ephemeral  nature  will  soon  become  plain, 
for  a  rest  of  a  few  days  suffices  for  its  disappearance. 

In  some  instances  resort  to  procedures  reminiscent 
of  antagonistic  gestures  seems  to  have  been  of  avail. 

One  of  our  patients,1  suffering  from  facial  tic,  was 
directed  to  perform,  as  far  as  practicable,  the  opposite 
movements  to  her  grimaces.  If  her  mouth  was  drawn 
to  the  right,  she  forthwith  made  a  corresponding  twitch 
to  the  left;  if  her  mouth  was  shut  spasmodically,  she 
was  instructed  to  open  it  widely  and  quickly.  By  such 
simple  methods,  applied  to  all  her  tics,  speedy  control 

1  FEINDEL,  "  Spasmes  grima^ants  de  la  face,  datant  de  trois  mois," 
Revue  de  psychologic  clinique  et  therapeutique,  April,  1899. 

21 


322          TICS  AND    THEIR    TREATMENT 

was  regained,  and  once  she  had  mastered  the  theory 
of  the  process,  the  practice  of  regular  exercises  and 
the  development  of  antagonistic  movements  soon 
effected  a  complete  cure. 

Training  of  the  antagonists  has  also  been  recom- 
mended by  Hartenberg,1  in  a  case  of  scratching  tic. 
The  patient  was  urged  to  approximate  the  hand  to  the 
affected  cheek  very  slowly,  and  almost  at  the  moment 
of  contact  the  order  was  given  to  extend  the  arm 
briskly;  this  gesture  of  opposition,  moreover,  was 
stimulated  by  faradisation  to  the  extensors  of  the 
forearm.  The  method,  of  course,  is  practically  identical 
with  that  adopted  by  Frenkel,2  of  Heiden,  who  provoked 
energetic  contractions  of  antagonistic  groups  by  teach- 
ing the  patients  to  overcome  increasing  resistances. 
Prudence,  however,  must  be  observed  in  carrying  out 
these  ideas,  otherwise  we  run  the  risk  of  replacing  one 
tic  by  another. 

After  the  above  general  sketch  of  the  essentials 
of  the  method,  we  may  give  examples  of  its  application 
to  particular  instances. 

For  a  tic  of  the  eyelids,  in  especial  for  blinking 
tics,  we  make  the  patient  open  and  shut  the  eyes  to 
order,  keep  them  closed  or  apart  for  a  space,  shut  one 
eye  and  then  the  other,  and  repeat  the  same  sequence 
in  different  positions  of  the  head.  It  is  a  good  plan 
to  enjoin  simultaneous  action  of  the  oral  musculature. 
The  cessation  of  tonic  contractions  of  the  eyelids  with 
opening  of  the  mouth  has  been  remarked  several  times, 
and  Oppenheim  finds  an  analogy  in  the  observations 

1  HARTENBERG,  "  Traitement  et  gu6rison  d'un  cas  de  tic  sans 
angoisse,"  Revue  de  psychologic  clinique  et  therapeutique,  January,  1899, 
p.  17. 

1  FRENKEL,    "  De   1'exercice    c6r6bral    appliqu6  au  traitement   de 
certains  troubles  moteurs,"  Semaine  medicale,  1896,  p.  124. 


TREATMENT  BY  RE-EDUCATION       323 

of  G-unn  and  Helfreich,  who  have  seen  ptosis  disappear 
as  the  mouth  is  opened. 

If  the  eyeballs  are  involved  in  a  tic,  insist  on 
dissociating  the  movements  of  head  and  eyes ;  make 
the  patient  follow  an  object  slowly  with  his  eyes 
while  the  head  is  stationary ;  or  let  the  head  deviate 
to  right  or  left,  up  or  down,  while  the  eyes  remain 
fixed  on  some  particular  point. 

When  the  lips  are  the  seat  of  involuntary  muscular 
action,  have  the  patient  show  his  teeth,  open  and 
shut  his  mouth,  purse  his  lips;  make  him  speak 
and  conform  his  expression  to  his  speech;  let  him 
read  aloud  slowly,  and  fix  his  attention  on  his 
subject. 

As  a  specimen  of  treatment  for  a  facial  tic,  we, 
may  cite  the  subjoined  programme  : 

Every  day,  and  three  times  a  day,  at  the  same  hours — nine,  one,, 
and  six — the  patient  is  to  look  at  himself  for  two  minutes  in  a 
mirror,  preserving  absolute  immobility  the  while  ;  to  read  aloud  for 
two  minutes,  to  speak  in  front  of  the  glass  for  two  minutes,  to  walk 
backwards  and  forwards  in  front  of  the  mirror  for  two  minutes.  During' 
the  ten  minutes  ot  these  exercises  he  will  endeavour  to  keep  his  facial 
musculature  under  control.  If  the  tic  assert  itself  in  the  course  of  one 
of  the  exercises,  he  will  recommence  the  latter,  if  necessary  twice  ;  the 
third  time  he  will  leave  it  till  the  next  seance. 

For  tics  of  the  head  and  neck,  such  as  tossing 
tics  and  mental  torticollis,  inclination  and  rotation 
movements  are  indicated,  of  which  an  instance  may 
be  quoted: 

Mademoiselle  R.  is  quick  in  learning  how  to  correct  her  muscular 
faults.  Her  actions  are  gradually  becoming  more  complete  and  ample,  and 
if  she  performs  her  allotted  task  with  little  animation,  at  the  least  there 
is  no  question  of  her  indefatigable  willingness.  In  less  than  a  month 
she  has  been  able  to  fix  her  regard,  open  her  eyes  widely,  turn  her 
head,  uninterrupted  either  by  halts  or  twitches  ;  she  can  remain  motion- 
kss  in  front  of  a  looking-glass  for  as  long  as  a  minute.  Equally 


324         TICS  AND   THEIR   TREATMENT 

satisfactory  progress  has  been  made  in  the  art  of  reading  aloud ;    she 
breathes  more  regularly,  and  articulates  more  distinctly. 

Thus  the  patient  has  come  to  realise  that  she  need  but  give  her 
attention  to  the  involuntary  movements  for  them  to  cease,  and  there 
has  been  a  synchronous  advance  in  her  mental  activity  and  power  of 
•concentration.  Her  nonchalance  and  timidity  have  diminished  ;  she  is 
no  longer  indifferent  to  her  surroundings,  nor  furtive  in  her  glances  ; 
she  enters  into  conversation  with  zest,  and  her  movements  are  characterised 
by  decision. 

Take  another  example  of  treatment,  for  a  case  of 
mental  torticollis  : 

Stand  or  sit  in  front  of  a  mirror  and  endeavour  to  maintain  an 
absolutely  correct  position  of  trunk  and  shoulders. 

Lift  the  arms  vertically  and  turn  the  head  to  the  right,  then  lower 
the  arms  while  the  head  remains  as  it  is. 

Bend  the  body  forward,  and  stretch  the  arms  out  till  they  touch 
the  ground,  the  head  meantime  being  rotated  to  the  right.  Then  rise 
up  again  with  the  head  in  the  same  attitude.  After  two  or  three 
efforts  it  will  be  found  that  the  head  can  be  kept  straight  for  a  few 
seconds. 

In  tics  of  the  limbs,  shoulders,  hands,  feet,  innumer- 
able movements  will  suggest  themselves  for  practice. 
The  young  girl  with  a  tic  of  genuflexion,  under  the 
care  of  Oddo,  supplies  an  excellent  proof  of  the  value 
of  Brissaud's  method  : 

The  immobilisation  of  movements  was  realised  by  the  mother  forcing 
the  child  to  remain  motionless  in  a  fixed  position  for  augmented  periods. 
As  for  movements  of  immobilisation,  the  patient  made  peregrinations 
of  increasing  length  under  the  mother's  eye,  the  order  being  repeatedly 
given  to  suppress  the  genuflexions.  At  the  same  time,  massage  and 
passive  movements  to  the  limbs  and  joints  were  prescribed,  with  a  view 
to  diminishing  the  articular  cracks — the  exciting  cause  of  the  bizarre 
tic  from  which  the  girl  suffered. 

In  the  course  of  ten  or  twelve  days  the  genuflexions  had  entirely 
vanished,  and  a  return  of  the  pain  in  the  coxo-femoral  articulation 
aided  materially  in  consolidating  the  effects  of  the  treatment. 

Tics  of  speech  should  be  handled  in  the  same  way 
as  stammering.  "We  do  not  treat  stammerers,  we 


TREATMENT  BY  RE-EDUCATION       325 

educate  them/'  says  Moutard-Martin.  There  can  be 
no  gainsaying  the  convincing  results  obtained  by 
Chervin's  technique. 

For  years  there  has  been  unanimity  of  opinion  on 
the  value  of  respiratory  gymnastics  in  the  treatment 
of  stammering.  The  plan  is  to  make  the  patient  inspire 
deeply  and  quickly,  and  follow  this  with  a  prolonged 
expiration.  Difficulties  of  articulation  and  phonation 
may  be  overcome  by  recitation,  by  declaiming,  by 
scanning  utterance,  by  dwelling  on  the  vowels,  etc. 
Various  authors  have  laid  stress  on  the  advisability 
of  concomitant  therapeutic  treatment. 

In  cases  of  stammering  (says  Olivier),  all  surgical  interference  is  to 
be  deprecated.  Operations  on  the  nose  or  throat  are  directed  toward  the 
removal  of  obstructions  in  the  air-ways,  but  they  are  merely  a  preparatory 
step  to  the  adoption  of  the  education  method.  No  one  of  the  vaunted 
"  cures  "  for  stammering  is  infallible,  since  all  depend  in  the  last  resort 
on  the  will  power  of  the  patient,  nor  is  there  anything  mysterious  about 
them.  Isolation  is  not  always  indicated  ;  what  is  indispensable  is 
reinforcement  of  the  will. 

The  intimate  relation  between  tics  of  speech  and 
various  kinds  of  stammering  has  led  to  the  application 
to  both  of  the  same  re-education  methods.  Pitres,1 
in  particular,  bases  his  line  of  treatment  for  tics  in 
general  on  regulation  of  respiratory  activity,  as  he 
has  observed  that  tics  diminish  or  die  away  with 
a  deep  and  regular  respiratory  rhythm.  His  plan  is 
as  follows: 

Supported  against  a  wall,  with  shoulders  braced  back,  the  patient 
is  instructed  to  take  slow  and  deep  inspirations,  raising  his  arms  the 
while,  and  letting  them  fall  with  expiration.  This  performance  is 
repeated  three  times  a  day,  for  ten  minutes  at  a  time. 

1  PITRES,  "Tics  convulsifs  gen6ralis6s  trait6s  et  gu6ris  par  la 
gymnastique  respiratoire,"  Journ.  de  medecine  de  Bordeaux,  February 
17,  1901,  p.  106. 


326          TICS  AND   THEIR   TREATMENT 

The  method  has  been  elaborated  by  Tissie*,  and 
Cruchet  also  has  thereby  obtained  excellent  results, 
which  he  has  put  on  record  in  his  thesis. 

The  patient  is  placed  upright  against  some  support,  his  heels  together 
and  his  arms  by  his  side.  For  the  first  three  minutes  he  recites  aloud, 
drawing  a  slow  deep  breath  at  frequent  and  regular  intervals.  Then 
he  proceeds  to  make  similar  long  inspirations  and  expirations,  elevating 
his  arms  synchronously  with  the  former,  and  depressing  them  with  the 
latter.  The  exercises  may  advantageously  be  repeated  every  three  hours  to 
begin  with,  then  their  duration  may  be  increased  and  the  intervals 
lengthened,  until  the  seances  are  extended  to  fifteen  minutes  three  times 
a  day.  Their  continuance  will  vary  with  the  individual,  but  the  ultimate 
aim  is  to  reduce  the  period  and  to  spin  out  the  interval  still  more, 
until  eventually  their  object  has  been  attained  and  they  may  cease. 

A  concrete  example  may  be  given : 

A  young  man  had  suffered  for  eleven  years  from  generalised  tics  of 
peculiar  intensity.  Every  few  seconds  violent  twitches  of  an  electric- 
like  rapidity  seized  the  muscles  of  his  head,  trunk,  and  limbs,  to  the 
accompaniment  of  abrupt  cries  and  inarticulate  growls.  A  sojourn  of  a  few 
weeks  in  hospital,  and  the  acquisition  of  the  most  elementary  technique  in 
athmotherapy,  resulted  in  a  complete  cure  ere  many  months  had 
passed. 

Tissie  explains  the  action  of  this  method  on  tics 
by  a  special  action  of  regular  respiration  on  psychomotor 
centres.  Raymond  and  Janet  incline  to  the  opinion 
that  attention  depends  on  respiratory  activity,  but 
Tissie l  argues  there  is  antagonism  between  deep 
respiration  and  maintenance  of  attention,  and  Cruchet 
supports  this  hypothesis. 

If  we  prescribe  respiratory  exercises,  we  are  temporarily  suppressing 
the  attention,  and  reducing  psychical  activity  to  a  minimum.  Thus  tic, 
which  is  a  reflex  of  thought,  does  not  occur,  and  if  the  exercises  are  renewed 
often  enough,  the  habit  will  gradually  be  lost. 

1  TISSIE,  "  Tic  oculaire  et  facial  accompagne  de  toux  spasmodique, 
traite  et  gueri  par  la  gymnastique  medicale  respiratoire,"  Journ.  de 
mtdecine  de  Bordeaux,  July  9  and  16,  1899. 


TREATMENT  BY  RE-EDUCATION       327 

In  our  opinion,  it  is  precisely  the  bestowal  of  the 
attention  on  the  allotted  task  that  has  such  a  salutary 
effect.  Whatever  be  the  movements,  they  demand  of 
the  patient  a  momentary  halt,  a  momentary  interrup- 
tion of  those  ill-timed  motor  reactions  that  make 
concerted  action  impossible.  Observation  shows  that 
the  degree  of  successful  control  is  in  proportion  to  the 
degree  of  concentration  of  the  attention.  The  novelty 
of  the  exercise  in  itself  acts  as  a  stimulus,  but  when 
this  novelty  wears  off,  faults  are  prone  to  reappear. 
Hence  the  necessity  of  varying  the  procedures,  and 
of  rendering  them  always  interesting ;  in  the  end  the 
habit  of  supervision  is  contracted,  and  the  patient  feels 
increasing  satisfaction  in  watching  his  physical  in- 
firmities daily  diminish  and  the  resources  of  his  will 
daily  widen. 

Respiratory  drill  is  an  admirable  method  of  procuring 
this  result ;  it  acts  in  the  same  way  as  any  of  the  other 
exercises.  Its  use  is  not  confined  to  tics  of  speech  or  of 
respiration,  for  thoracic  muscles  are  involved  in  tic 
much  more  frequently  than  is  commonly  supposed.  By 
resort  to  this  technique  Madet  cured  an  expiratory 
hiccough 1  in  a  man  of  forty-six,  who  was  afflicted 
in  addition  with  twitches  of  head,  trunk,  and  hands. 

Systematised  exercises  have  of  course  the  advantages 
of  exercise  in  general ;  motor,  sensory,  and  psychical 
functions  alike  are  stimulated  and  regulated,  and  tend 
to  become  normal.  In  particular,  muscular  exercise  is  a 
striking  way  of  disciplining  volition.  Accordingly,  we 
never  fail  to  prescribe  such  pastimes  as  gymnastics,  in 
any  of  its  forms,  rowing,  fencing,  cycling,  lawn  tennis, 
etc. ;  games  which  demand  attention,  skill,  and  decision 
are  useful  auxiliaries,  and  manual  occupations  of  a 
more  delicate  nature  ought  not  to  be  forgotten,  provided 

1  MADET,  "  Myoklonie  in  der  Art  eines  expiratorischen  Singultus," 
Weiner  medic.  Blatter,  No.  30,  1899. 


328          TICS  AND   THEIR   TREATMENT 

they  require  of  the  patient  a  certain  amount  of  im- 
mobility. Every  case,  needless  to  say,  must  be  treated 
on  its  merits,  but  the  general  indications  we  have 
supplied  can  easily  be  modified  to  suit  the  individual. 

The  various  procedures  directed,  under  different 
names,  to  the  suppression  of  tic  by  re-education,  are  all 
modelled  on  the  same  plan.  Koster  attributes  the 
disease  to  exhaustion  of  higher  co-ordinating  centres, 
and  counsels  their  reinforcement  by  appropriate  exercise. 
Oppenheim,in  laisLehrbuch  der  Nervenkrankheiten,  adduces 
evidence  of  the  value  of  what  he  calls  Hemmungstherapie, 
which  is  merely  an  application  of  the  principles  and 
therapeutic  rules  laid  down  by  Brissaud  in  1893,  and  des- 
cribed by  one  of  us  in  1897,  apropos  of  mental  torticollis. 
The  same  may  be  said  of  the  line  of  treatment  pursued 
by  Dubois,  which  appears  to  be  based  on  the  pathogenic 
interpretation  given  by  Oettinger,1  according  to  whom 
the  brain  of  tic  patients  is  incapable  of  conserving  the 
image  of  sustained  immobility,  and  thereby  loses  the 
habit  of  voluntary  immobilisation.  The  essence  of 
treatment,  therefore,  consists  in  habituating  the  subject 
to  rest  motionless  like  a  statute  in  a  position  conducive 
to  repose,  and  for  a  given  time. 

As  has  been  already  remarked,  the  polymorphism 
of  tics  is  such  that  the  plan  of  treatment  selected 
must  be  necessarily  elastic  if  it  is  to  be  altered  to  suit 
individual  cases.  What  is  the  point  in  enjoining 
absolute  immobility  on  a  patient  whose  blepharotic 
is  never  in  evidence  unless  he  is  walking  about  ? 

We  may  now  proceed  to  narrate  the  details  of 
various  cases  of  tic  treated  by  the  combined  method 
of  disciplinary  movements  and  immobility,  taking  the 
history  of  0.  as  our  first  example. 

1  OETTINGER,  "  The  Disease  of  Convulsive  Tic,"  Amer.  Jour*,  of 
the  Med.  Sc.,  September,  1899,  p.  303. 


TREATMENT  BY  RE-EDUCATION       329 

October  15,  1901. — Seance  of  absolute  immobility  in  the  upright 
position,  with  the  head  straight,  for  five  seconds  ;  to  be  repeated  in  front 
of  a  mirror  for  five  minutes,  with  intervals  for  rest  of  fifteen  seconds. 
Movements  of  rotation  of  the  head  to  left  and  right,  with  progressively 
lengthening  pauses  in  each  of  the  extreme  positions.  Respiratory 
exercises  with  elevation  and  depression  of  the  arms  eight  times  a  minute, 
decreasing  steadily  to  four  a  minute.  These  exercises  are  to  occupy 
a  quarter  of  an  hour  morning  and  evening.  Explain  to  the  patient 
the  action  of  the  sternomastoids  and  how  they  combine  to  fix  the 
head.  Make  the  patient  lie  on  his  back  and  move  his  head  antero- 
posteriorly. 

October  19. — O.  has  still  his  tics,  but  he  can  already  remain 
motionless  on  command,  and  is  conscious  of  satisfaction  in  so  doing.  Just 
as  his  exercises  come  to  an  end  there  is  always  a  momentary  recrudescence 
of  the  tics,  but  a  very  appreciable  calm  follows. 

October  zi. — Immobility  is  maintained  well  for  half  a  minute.  The 
patient  is  to  resume  his  cycling  and  fencing,  physical  exercises  which  he 
has  abandoned  for  more  than  a  year. 

October  25. — O.  considers  himself  greatly  improved.  He  has  gained 
insight  into  the  way  of  combating  his  tics,  and  his  self-confidence  is  on 
the  up  grade.  For  several  days  he  has  devoted  his  attention  to  his  tic  of 
blinking,  with  the  result  that  he  can  open  his  eyes  longer  and  more 
easily. 

October  28. — He  evinces  a  preference  for  certain  of  the  exercises  :  if 
they  please  him,  he  performs  them  accurately  ;  if  they  do  not,  they  are 
neglected. 

November  20. — The  head  tics  are  still  rather  violent  at  times.  A  period 
of  intellectual  and  bodily  fatigue  has  supervened,  but  he  tries  his  fencing 
again,  and  to  his  profound  satisfaction  he  has  managed  to  keep  free  of 
tics  during  the  bouts.  He  is  recommended  to  avoid  all  possible  causes 
of  cerebral  and  physical  exhaustion. 

December  3. — He  continues  to  make  satisfactory  progress.  His  habit 
of  supporting  his  chin  on  his  cane  is  abandoned,  though  an  attempt  to 
dispense  with  the  latter  entirely,  when  he  is  out  in  the  street,  has  ended 
disastrously.  He  is  content  to  hold  it  in  his  hand  and  strike  his  leg  with 
it  from  time  to  time. 

December  13. — Whenever  O.  is  tempted  to  tic  again,  he  stands  in  front 
of  a  mirror  and  commences  to  sing,  and  while  the  song  lasts  his  tics  remain 
in  abeyance.  His  trick  of  sitting  crossways  on  a  chair  and  rubbing  his 
chin  against  the  back  is  also  discarded,  with  the  result  that  the  callosities 
have  vanished.  As  far  as  his  walking  is  concerned,  he  has  adopted  the 
plan  of  endeavouring  to  get  from  one  point  to  another  without  allowing 
his  tics  to  assert  themselves,  and  his  efforts  have  been  crowned  with 
success. 

February  3. — The   patient  has   recovered  his   self-confidence,  and  the 


330          TICS  AND   THEIR    TREATMENT 

compliments  of  his  friends  prove  an  additional  restorative.  It  is  true 
the  tics  still  recur,  but  their  number  is  less,  their  duration  shorter,  their 
seyerity  considerably  diminished.  What  O.  is  best  able  to  appreciate 
is  the  disappearance  of  the  state  of  mal  obiidant  that  accompanied  them. 

Take  another  example  in  the  person  of  young  J. : 

In  his  case  our  object  was  to  discipline  him  by  successive  modifications 
of  his  caprices.  The  first  important  result  achieved  was  the  suppression 
of  his  precious  mattress — a  result  not  obtained  without  difficulty,  for 
the  mere  mention  of  it  sufficed  to  provoke  floods  of  tears  and  ebullitions 
of  anger.  He  was  then  sent  into  the  country  for  a  few  days  to  forget 
his  heart's  desire,  but  the  labour  was  lost.  No  sooner  had  he  arrived  than 
he  discovered  another  mattress  in  a  barn,  and  transferred  his  affections 
to  it. 

Eventually  the  day  came  when  he  was  finally  convinced  of  the 
absurdity  and  inconvenience  of  his  practice,  and  when  the  tender  yet 
firm  remonstrances  of  his  parents  prevailed.  The  prospect  of  congratula- 
tions awaiting  him,  and  his  own  keenness  to  get  better,  stimulated  him  to 
fresh  efforts,  and  the  reward  was  success. 

Not  long  after,  however,  he  began  to  complain  of  mental  suffering 
from  the  restraint  laid  on  him,  and  the  distress  was  undoubtedly  genuine. 
We  accordingly  gave  him  permission  to  stretch  himself  on  his  bed  at 
certain  fixed  times  and  for  a  fixed  period,  which  was  to  be  reduced  each 
day  by  some  minutes.  He  entered  into  the  spirit  of  the  regulations  so 
happily  that  in  less  than  a  month  the  period  spent  in  the  horizontal 
position  had  sunk  from  two  hours  and  three  quarters  to  an  hour  and 
a  half  daily,  and  at  last  it  was  dispensed  with  altogether. 

On  his  "  nervous  movements "  re-education  by  immobility  and 
methodical  exercises  had  a  beneficial  influence,  and  he  acquired  the 
faculty  of  controlling  his  variable  and  attitude  tics.  Repetition  of  the 
stances  under  the  eye  of  the  physician,  drill  in  front  of  a  looking-glass, 
symmetrical  and  synchronous  exercises  for  the  arms,  as  well  as  ordinary 
practice  in  dressing  and  undressing,  buttoning  and  unbuttoning  clothes, 
eating,  drinking,  etc.,  with  the  left  hand — all  contributed  materially 
to  his  progress.  Many  other  re-educative  prescriptions  were  enjoined 
on  the  patient  ;  suffice  it  to  say  that  in  three  months  he  was  able  to 
dress  and  feed  himself,  to  behave  properly  at  table,  and  to  restrain  himselr 
generally,  in  spite  of  the  obstacles  provided  by  his  babyish  tricks  and 
natural  weakness. 

Further,  the  advance  he  has  made  has  reacted  profitably  on  his 
mental  condition,  and  if  his  fickleness  and  vacillation  persist,  at  the  least 
the  trend  of  the  educative  exercises  has  been  in  the  direction  of  rein- 
forcement of  the  will.  Hence  is  it  that  he  is  now  more  attentive,  less 
introspective,  less  capricious  ;  he  is  no  longer  overwhelmed  at  the  gravity 


TREATMENT  BY  RE-EDUCATION       331 

of  his  condition  ;  he  is  conscious  of  having  taken  its  measure,  and  of 
his  power  to  master  it. 

We  have  also  applied  Brissaud's  method  to  the 
treatment  of  variable  chorea,  with  no  less  encouraging 
results.  Its  worth  in  cases  of  mental  torticollis  has 
been  noted  by  several  authors  as  well  as  by  ourselves. 
A  cure  resulted  in  a  peculiarly  difficult  instance  recorded 
by  Martin l : 

A  young  man  of  twenty-six  suffered  from  melancholia  and  hypochon- 
driasis.  He  used  to  complain  that  his  limbs  were  hopelessly  rotten,  that  his 
hands,  feet,  legs,  were  gone,  vanished  ;  his  head  and  neck  had  ceased  to 
exist.  So  easily  was  he  irritated  that  to  most  questions  he  vouchsafed 
no  answer.  His  sentiments  of  affection  were  much  blunted  ;  a  visit  from 
his  mother  evoked  no  pleasurable  sensation.  All  day  long  he  used  to 
lounge  on  a  couch,  his  head  sunk  on  his  breast,  and  inclined  somewhat 
to  the  right.  The  attitude  was  exaggerated  if  he  was  addressed,  but 
while  he  could  raise  his  head,  by  the  help  of  his  hand,  to  regard  his 
interlocutor,  it  resumed  its  position  of  flexion  as  soon  as  he  withdrew 
the  support.  Confined  to  the  left  side  of  his  face  was  a  tic  which 
consisted  in  abrupt  and  jerky  elevation  of  the  corner  of  the  mouth.  On 
request,  he  would  gain  his  feet  laboriously  and  walk  with  abdomen 
protuberant,  back  arched,  and  legs  apart.  From  time  to  time  the  neck 
musculature  on  the  left  side  was  the  seat  of  convulsive  movements.  The 
left  sternomastoid  and  trapezius  were  in  a  state  of  tonic  contraction,  and 
on  any  attempt  being  made  to  correct  this  vicious  attitude,  spasm  occurred, 
and  the  patient  resisted  to  his  utmost. 

On  March  10,  1900,  treatment  was  begun  5  an  effort  was  made  to 
gain  the  patient's  confidence  by  explaining  that  a  cure  was  within  the 
bounds  of  possibility,  and  by  demonstrating  to  him  that  his  limbs, 
which  were  in  a  state  of  slight  contracture,  could  be  moved  by  his  hand. 
The  procedure  was  renewed  three  times  a  day,  and  followed  by  baths 
and  massage. 

By  April  15  the  contractures  had  disappeared,  and  he  could  per- 
form any  movement  of  relaxation  himself.  His  attention  was  now  drawn 
more  particularly  to  his  head,  which  was  still  in  a  faulty  position, 
and  annoyed  him  considerably.  Advantage  was  taken  of  an  im- 
provement in  his  tractability  to  make  him  perform  some  movements 
of  his  neck.  At  first  the  mere  effort  produced  a  spasmodic  contraction 
but  he  was  able  to  move  his  head  very  slightly  up  and  down.  After 
fire  months  of  such  treatment,  occupying  on  an  average  three  hours  a 

1  MARTIN,  Congres  de  Limoges ;  1901 


332          TICS  AND   THEIR   TREATMENT 

day,  his  mental  torticollis  was  finally  reduced  to  subjection,  an  interesting 
feature  of  the  case  being  the  parallelism  between  the  physical  and  the 
psychical  improvement. 

On  three  occasions  since  we  have  noted  a  recurrence  of  the  torticollis, 
but  each  time  it  has  been  both  brief  and  easily  overcome.  The  cure 
has  been  maintained  now  for  upwards  of  a  year,  and  four  months  ago 
the  patient  resumed  his  work. 

We  must  impress  ourselves  with  the  importance  of 
recognising  the  proneness  of  tics  to  relapse.  Any 
triviality  which  may  have  a  prejudicial  effect  on  the 
patient's  will-power  is  calculated  to  facilitate  the  re- 
awakening of  a  bad  habit.  Such  relapses  are  commonly 
transient,  and  are  instructive  in  so  far  as  their  mani- 
festation sometimes  differs  from  the  original  tic  and 
entails  alterations  in  treatment. 

L.,  for  instance,  whose  condition  was  one  of  permanent  rotation 
of  the  head  to  the  right,  had  a  fit  of  depression  after  eight  days  of 
treatment  and  noteworthy  improvement,  a  depression  so  severe  that 
she  questioned  the  practicability  of  a  cure,  and  forthwith  her  head  began 
to  turn  to  the  right  again.  On  this  occasion,  however,  the  tic  was 
an  intermittent  one,  consisting  of  clonic  contractions  of  the  cervical 
muscles  chiefly,  without  antagonistic  gesture.  For  five  days  the  fit 
persisted,  and  was  sufficiently  acute  to  render  omission  of  the  exercises 
advisable. 

After  some  days*  rest  a  beginning  was  made  with  the  treatment 
again,  under  the  direction  of  one  of  us  and  in  the  presence  of  her 
father.  We  took  care  to  place  ourselves  always  in  front  and  to  the 
left  of  the  patient,  on  the  side  opposed  to  her  torticollis.  The  position 
allotted  her  at  table  was  such  that  in  order  to  converse  with  her  parents 
she  had  to  turn  to  the  left. 

Not  long  thereafter  a  second  fit  of  depression  occurred,  but  on 
this  occasion  her  head  began  to  rotate  to  the  left.  She  had  been 
under  treatment  for  six  weeks,  when  she  made  the  remark  one  day 
that  her  head  seemed  once  more  to  be  drawn  to  the  right.  She  hastened 
to  add,  moreover,  that  she  had  discovered  a  means  of  remedying  the 
mischief — viz.  by  putting  her  left  hand  to  her  left  cheek — a  corrective 
proceeding  nothing  short  of  paradoxical. 

It  was  about  this  time  that  the  pains  and  dragging  sensations  in 
the  muscles  of  the  neck  subsided.  On  the  other  hand,  for  days  on 
end,  then  for  gradually  diminishing  periods,  there  existed  a  slight 


TREATMENT  BY  RE-EDUCATION       333 

trembling  of  the  head,  due  to  muscular  exertion,  and  explicable  by  the 
contraction  of  small  cervical  muscles  on  one  side  and  their  antagonists 
.on  the  other. 

On  more  than  one  occasion  we  have  remarked  this 
trembling  as  the  forerunner  of  a  cure.  It  vanishes 
spontaneously  as  the  amelioration  of  the  patient's 
condition  becomes  more  definite. 

Several  months  may  intervene  between  relapses. 
Descroizilles  cites  a  case  of  convulsive  movements  of 
-the  head  and  shoulder  of  three  years'  duration,  which 
yielded  to  exercises  in  a  few  weeks.  The  tic  reappeared 
six  months  later,  and,  resisting  treatment  by  gymnastic 
discipline,  was  cured  by  suspension.  Three  months 
later  it  returned  once  more. 

Facts  of  this  description  emphasise  the  desirability 
of  considering  rapid  cures  with  reserve ;  where  the 
improvement,  on  the  contrary,  is  insensible,  the 
results  are  much  more  likely  to  be  permanent.  Un- 
foreseen complications,  a  again,  may  arise  once  a  cure 
is  affected. 

One  of  our  patients  J  had  been  rather  quickly  relieved  of  a  mental 
torticollis  by  the  usual  therapeutic  measures,  and  we  had  allowed  him 
to  resume  his  avocation,  when  he  suddenly  appeared  in  a  depressed 
and  despairing  mood  a  month  later  to  say  that  he  was  worse  than  ever. 
The  rotatory  tic  had  not  returned,  it  is  true,  but  its  place  was  taken 
by  another  phenomenon.  If,  as  he  walked  along  with  head  straight, 
his  attention  was  suddenly  directed  to  the  right,  he  seemed  at  once  to 
become  "  crystallised "  ;  he  halted,  and  could  not  deviate  his  head  as 
he  wanted,  and  at  the  same  moment  something  appeared  to  choke  him  ; 
in  three  or  four  seconds  all  was  over,  and  his  action  unimpeded.  As 
a  result  of  these  attacks  he  sank  into  a  wretched  state  of  more  or  less 
permanent  anguish.  A  visit  to  his  country  home  was  of  little  avail  ; 
no  sooner  had  he  arrived  than  his  head  began  to  twist  about  in  every 
direction,  although,  try  as  he  would,  he  could  not  move  it  backwards. 
We  accordingly  prescribed  absolute  rest  in  bed,  a  strict  regime, 

1  BRISSAUD  AND  FEINDEL,  "Sur  le  traitement  du  torticolis  mental 
-^t  des  tics  similaires,"  Journ.  de  neurologie,  April  15,  1899. 


334          TICS  AND    THEIR    TREATMENT 

hydrotherapy,  and  unfailing  regularity  in  the  performance  of  gymnastic 
exercises.  Not  long  after  a  fresh  torticollis  developed,  by  which  the 
chin  was  deviated  to  the  left  and  the  head  tilted  to  the  right.  Once 
more  we  initiated  a  scheme  of  regular  drill,  and  in  the  course  of  a 
short  time  a  satisfactory  cure  ensued.  During  the  last  three  years  we 
have  had  frequent  opportunities  of  seeing  our  patient,  and  can  certify 
that  he  remains  mentally  and  physically  normal. 


Facts  such  as  these  teach  us  two  things:  the  task 
of  the  physician  is  not  ended  with  the  disappearance 
of  the  tic,  for  it  is  the  pathological  mental  state  of 
the  patient  which  renders  him  so  easy  a  prey,  and  if 
we  can  modify  that  state  by  re-education,  we  may  count 
on  the  cure  being  permanent.  For  a  long  time,  how- 
ever, we  shall  be  well  advised  to  talk  simply  of 
improvement.  In  the  second  place,  relapse  or  slowness 
of  progress  is  no  reason  for  despair ;  treatment  may 
have  to  be  persevered  with  for  a  year  or  years,  till 
the  patient  learns  how  his  muscles  act,  how  to 
maintain  immobility,  and  how  to  effect  a  voluntary 
movement — notions  which  his  fickle  mind  has  hitherto 
neglected  to  grasp.  Education  of  the  will  in  the 
direction  of  control  is  calculated  to  bring  him  into  line 
with  normal  individuals. 

A  radical  cure  is  not  without  the  bounds  of 
possibility,  but  it  depends  greatly  on  the  patient 
himself;  his  success  is  contingent  on  his  faithful 
repetition  of  exercises  long  after  the  tic  is  gone ;  for 
while  a  cure  results  whenever  the  tic  ceases  to  in- 
commode its  subject,  fatigue  or  emotion  on  some  future 
occasion  may  reawaken  the  tendency  to  involuntary 
movements,  and  only  a  methodically  trained  will  can 
triumph  over  the  temptation  to  relapse. 

With  this  reservation,  one  may  expect  permanence 
in  the  cure,  provided  the  affection  is  of  recent  date 
and  the  patient  gives  evidence  of  his  assiduity  and 
desire  for  relief. 


TREATMENT  BY  RE-EDUCATION       335 


MIRROR    DRILL 

Among  various  re-educational  procedures  which  are 
worth  mentioning  for  their  practical  value,  a  place 
must  be  given  to  what  has  been  called  mirror  drill 
by  one  of  us. 

We  all  know  that  the  term  mirror  writing  is  in 
use  to  specify  that  mode  of  caligraphy  which  looks 
exactly  like  ordinary  writing  when  it  is  reflected  in  a 
mirror  or  if  the  paper  is  held  to  the  light  and  seen 
from  the  reverse  side.  Mirror  handwriting  may  be 
done  with  either  hand.  If  the  right  hand  be  employed, 
the  characters  are  traced  from  right  to  left  and  are 
centripetal  in  relation  to  -the  axis  of  the  body.  If,  on 
the  contrary,  it  is  the  left  hand  that  we  use,  the 
letters  go  from  right  to  left,  but  they  are  centrifugal. 

Innumerable  examples  of  this  condition  have  been 
described  and  various  theories  elaborated.  Apart  from 
such  cases,  it  is  a  matter  of  common  observation  that  if 
any  one  be  asked  to  write  synchronously  with  the  two 
hands,  his  left  hand  will  tend  spontaneously  to  adopt 
the  mirror  form.1  The  experiment  may  be  tried  on 
some  one  who  has  never  made  the  attempt  to  write 
with  the  left  hand,  and  has  never  heard  of  mirror 
writing.  Ask  him  to  abandon  his  left  hand  completely 
to  the  movements  it  may  be  constrained  to  fashion 
while  the  right  hand  is  tracing  the  required  words,  and 
let  his  eyes  be  closed ;  in  practically  every  case  the 
left  will  make  mirror  characters.  It  may  therefore 
be  contended  that  mirror  writing  is  the  natural  writing 
of  the  left  hand,  an  opinion  supported  by  Vogt,  Durand, 
etc.,  and  more  recently  by  Ballet,2  who  remarks  that 

1  MEIGE,  Congres  du  Limoges •,  1901. 

*  BALLET,  "  L'ecriture  de  Leonard  de  Vinci :  contribution  a  1'etude 
de  1'ecriture  en  miroir,"  Nou-v.  icon,  de  la  Salpetriere,  1900,  p.  597. 


336         TICS  AND    THEIR    TREATMENT 

this  variety  of  writing  for  the  left  hand  is  natural 
in  left-handed  people  who  have  not  been  influenced  by 
education. 

The  actual  form  of  the  characters  is  of  little 
significance.  We  have  often  repeated  the  experiment 
and  substituted  Greek,  German,  typographic  and 
stenographic  letters,  but  always  with  the  same  result. 
It  is  perhaps  worthy  of  note  that  in  simultaneous 
writing  considerable  modification  of  the  letters  traced 
by  the  right  hand  occurs ;  they  become  hesitating 
and  childish  ;  the  lines  are  sinuous  and  irregular,  and 
the  characters  themselves  ill  distinguished.  The  same 
holds  good  for  drawings. 

On  the  other  hand,  the  first  attempt  of  the  left  to 
make  mirror  writing  to  order  is  frequently  laborious. 
Mingled  with  true  mirror  characters  will  be  found 
ordinary  letters  automatically  traced,  for  automatism 
of  left-hand  movements  is  not  the  inevitable  sequel  of 
automatism  of  right-hand  movements.  From  time 
to  time  the  visual  image  of  a  normal  letter  rises  in  the 
mind,  an  image  which  does  not  correspond  to  that 
which  the  hand  is  endeavouring  to  express,  whence 
doubt,  reflection,  arrest,  and,  usually,  error.  If,  however, 
the  subject  allows  his  left  hand  to  write,  without 
preoccupying  himself  with  the  shape  of  the  letters 
it  is  making,  or  with  his  eyes  shut,  automatism 
reasserts  its  sway  and  mirror  writing  results. 

Of  course  a  person  who  is  asked  for  the  first  time  to 
use  his  left  hand  in  writing  may  force  himself  to  trace 
ordinary  characters,  but  to  do  so  he  must  evoke  the 
visual  image  of  each  letter  and  seek  to  reproduce  the 
contours  of  this  image  slowly,  yet  often  inaccurately. 
There  is  nothing  automatic  in  this.  Hence  it  is  that 
ordinary  writing  with  the  left  hand  demands  prolonged 
education  and  patient  effort,  and  may  never  attain 
any  rapidity,  whereas  mirror  writing  with  the  same 


TREATMENT  BY  RE-EDUCATION       337 

Land  is  acquired  with,  facility  in  a  more  or  less  automatic 
manner. 

It  may  well  be  that  the  natural  left-hand  mirror 
writing  of  which  we  are  speaking  is  a  purely  motor 
phenomenon,  since  the  calling  up  of  the  visual  images 
of  letters,  so  far  from  proving  of  assistance,  is  calculated 
rather  to  obscure  and  hamper  it. 

It  has  been  pointed  out  by  Ballet  that  variations  in 
the  aptitude  for  left-hand  mirror  writing  exist,  especially 
in  the  case  of  those  who  cannot  write  without  the 
aid  of  the  visual  image  of  letters.  Since  they  copy  this 
image  in  using  the  right  hand  for  caligraphical  purposes, 
they  are  tempted  to  do  the  same  when  the  left  is  in  use. 
In  fact,  the  facility  with  which  one  learns  mirror 
writing  seems  to  depend  on  one's  power  of  writing 
without  recourse  to  these  images.  The  explanation 
of  the  ease  with  which  the  left  hand  reproduces,  in 
the  guise  of  mirror  writing,  the  movements  of  the 
other,  is  to  be  sought  in  the  symmetrical  arrangement 
of  the  muscles  in  relation  round  the  body  axis. 
Physiologists  tell  us,  further,  that  the  simultaneous 
contraction  of  two  symmetrical  muscles  is  more  readily 
attained  than  that  of  two  asymmetrical  muscles.  The 
law  of  symmetry  and  the  law  of  least  effort  correspond. 

What  is  true  of  writing  is  no  less  true  of  all  other 
forms  of  motor  activity.  In  physical  exercises  the 
surest  results  are  achieved  by  the  synchronous  con- 
tractions of  symmetrical  muscles,  whereas  education 
is  much  more  arduous  should  this  lesson  from  experience 
be  ignored.  For  instance,  nothing  is  easier  than  to 
make  the  arms  describe  circles  in  the  same  direction, 
but  rotation  in  opposite  directions  is  very  difficult.  Few 
people  can  revolve  their  thumbs  in  opposite  ways. 
This  is  a  matter  of  common  observation  among  teachers 
of  physical  culture.  The  rapidity  with  which  the 
action  of  swimming  can  be  learned  is  in  striking 

22 


338         TICS  AND   THEIR   TREATMENT 

contrast  to  the  slowness  with  which  the  art  of  fencing 
is  apprehended.  Little  effort  is  required  of  the  music 
beginner  if  his  pianoforte  exercises  demand  the 
activity  of  symmetrical  muscles  for  their  execution  ; 
on  the  other  hand,  the  playing  of  a  scale  by  the  two 
hands  in  unison  comes  only  with  long  practice,  since 
it  entails  the  simultaneous  use  of  asymmetrical  muscles. 
Facts  such  as  these  are  of  more  than  passing  interest. 
One  cannot  afford  to  neglect  their  import  where 
muscular  education  is  concerned,  whatever  be  its  nature, 
whatever  be  its  object.  Yet  there  is  an  unfortunate 
tendency  to  concentrate  attention  on  the  development 
of  the  skill  of  one  arm  only,  and  that  the  right. 
Sometimes  the  use  of  the  left  arm  for  certain  purposes 
is  criticised  adversely,  and  of  course  most  people  are 
congenitally  less  able  to  work  with  it.  But  habit, 
example,  and  even  fashion,  combine  to  render  the 
right  arm  preponderant  in  everything,  to  the  detriment 
of  the  other.  It  is  a  common  occurrence  to  attribute 
awkwardness  to  this  left  arm,  when  its  inferiority  is 
really  nothing  else  than  a  sign  of  faulty  education.  In 
many  cases  the  left  is  as  good  as  the  right ;  its  apparent 
gaucherie  is  because  of  its  attempt  at  executing  move- 
ments which  are  similar  to  those  of  the  right,  instead  of 
those  which  are  correspondingly  opposite. 

Thus  experience  shows  that  the  education  of  the 
right  upper  limb  is  reflected  on  the  left  upper  limb, 
although  the  subject  may  be  sublimely  ignorant  of  the 
fact.  But  though  this  influence  be  latent,  it  is  none  the 
less  real,  and  may  prove  of  service  if  occasion  arise. 
Weber,  Fechner,  and  Fere 4  have  all  devoted  attention 
to  this  subject. 

From  the  therapeutic  point  of  view,  considerable 
significance  attaches  to  these  facts.  Temporary  dis- 

1  F!RE,  "L'influence  sur  le  travail  volontaire  d'un  muscle  de 
I'activit6  d'autres  muscles,"  Nowu,  icon,  de  la  Salpetriere,  1901,  p.  432. 


TREATMENT  BY  RE-EDUCATION       339 

ablement  of  the  right  arm,  such  as  follows  fracture 
or  arthritis  or  writers'  cramp,  need  not  be  disconcerting, 
for  the  patient  can  proceed  to  utilise  the  faculty  for  mirror 
writing  which  his  left  hand  has  unconsciously  acquired. 
In  all  affections   which   are  accompanied   by   troubles 
of  motility  it  is  an  excellent  plan  to  apply  the  prescribed 
muscular  exercises  to  both  sides  of  the  body,  and  the 
regularity  with  which  they  are  performed  on  the  sound 
side    will   have   a   corrective   influence   on    the   mirror 
movements  of  the  affected  side.     We  assume,  of  course, 
that  there  is  no  irremediable  destructive  lesion  which 
interferes  with  the  continuity  of  paths  joining  functional 
centres,  otherwise  the   education  of  the  normal  limbs 
could  not  be  expected  to  produce  any  beneficial  effect 
on  the  other.    It  is  especially  in  motor  disorders  of  func- 
tional origin  that  mirror  movements  prove  useful,  and  the 
frequent  unilaterality  of  these  disorders  readily  allows 
of  the  institution  of  a  re-educative  mirror  drill.     Speak- 
ing generally,  the  faculty  of  writing  supplies  us  with 
the  best  means  of  attaining  our  end,  for  the  variety  of 
exercises  it  offers  is  likely  to  rivet  the  patient's  attention, 
and  he  has  proofs  of  his  progress  under  his  eyes.     The 
goal  in  view  is  not,  of  course,  the  attainment  of  cali- 
graphical    perfection — the  subjects   of  tic   are   seldom 
guilty  of  bad  penmanship  ;    but  the  execution  of  the 
required   movements   demands   a  voluntary   constraint 
that  cannot  but  be  profitable. 

After  the  seances  of  absolute  immobility,  then,  our 
custom  is  to  set  daily  exercises  in  writing,  drawing, 
painting,  tracing,  ornamentation,  etc.,  varying  the 
indications  in  accordance  with  individual  tastes  and 
aptitudes.  At  the  same  time,  we^insist  on  the  patient's 
devoting  both  hands  simultaneously  to  his  task.  It  will 
be  found  advantageous  to  devise  movements  for  the 
fingers,  then  for  the  hand,  the  forearm,  and  so  on,  and 
to  instruct  him  in  each  successively.  Thus,  one  may 


340         TICS  AND   THEIR    TREATMENT 

begin  by  having  him  make  the  movements  in  space, 
then  with  chalk  on  a  blackboard  placed  vertically,  then 
on  the  same  placed  horizontally,  or  on  the  ground ; 
or  he  can  be  asked  to  trace  symmetrical  designs  and 
ornaments  on  a  wall.  The  essential  points  are  that 
he  use  both  arms  simultaneously,  symmetrically,  and  ac- 
curately, and  that  all  inopportune  gestures  be  inhibited. 

In  several  of  our  cases  procedures  such  as  these 
have  been  adopted.  0.  was  not  long  in  acquiring 
the  faculty  of  writing  with  both  hands,  the  left  tracing 
mirror  characters.  The  object  of  the  exercise  was 
to  oblige  him  to  maintain  tranquillity  and  a  correct 
position  of  his  head  and  neck,  while  his  hands  were 
simultaneously  employed.  By  this  means,  as  well  as 
by  synchronous  drawing  exercises,  he  soon  became 
so  deft  that  he  learned  to  conserve  almost  complete 
immobility  during  the  performance,  to  his  great  satis- 
faction. No  less  creditable  results  were  attained  with 
L.  and  with  young  J. 

The  -method  appears  to  us  to  be  indicated  above 
all  in  cases  where  the  left  arm  is  the  seat  of  tic. 
Any  one  who  can  use  a  pen  with  his  right  hand  is  not 
long  in  acquiring  the  faculty  of  mirror  writing  with 
his  left.  In  this  way  the  simultaneous  execution  of 
a  normal  movement  with  right  hand  and  left  is  facili- 
tated, and  the  sound  limb  imposes  regularity  on  the 
other.  Whatever  be  the  localisation  of  the  tic  or  tics, 
this  is  the  technique  to  adopt.  It  presents  this  ad- 
vantage, that  its  combinations  and  permutations  servo 
to  stimulate  the  patient's  interest,  and  he,  at  the  same 
time,  is  required  to  keep  a  watchful  eye  on  his  in- 
voluntary actions ;  so  is  his  will  disciplined. 

REST  IN   BED 

In  the  majority  of  cases  absolute  rest  in  bed  is  not 
desirable,  but  a  youthful  patient  should  always  be  sent 


TREATMENT  BY  RE-EDUCATION       341 

to  bed  early,  and  be  allowed  to  lie  long ;  twelve  hours 
in  bed  is  not  excessive.  This  rule  is  one  which  must  not 
permit  of  exceptions ;  whatever  be  the  excuses  invented 
by  the  parents,  we  should  see  that  it  is  rigorously 
obeyed.  Two  or  three  hours'  rest  some  time  in  the 
course  of  the  day  may  be  enjoined,  provided  the  period 
be  fixed  and  uninterrupted.  To  break  in  on  frequent 
siestas  with  little  promenades  or  with  times  of  unrest 
is  not  productive  of  any  good. 

If  it  is  impossible  to  maintain  discipline  during  the 
day,  absolute  rest  in  bed  for  a  longer  or  a  shorter 
period  may  be  counselled;  the  sedative  effect  of  this 
measure  cannot  be  gainsaid,  especially  when,  for  no 
apparent  reason,  exacerbations  develop,  with  increase 
of  emotional,  obsessional,  or  other  psychical  phenomena. 

ISOLATION 

Isolation  is  a  rather  severe  proceeding,  which, 
however,  one  must  not  hesitate  to  utilise  in  rebellious 
cases,  or  if  the  patient's  mental  state  precludes  the 
possibility  of  prolonged  application  of  systematic  dis- 
cipline. Wyemann 1  cites  a  successful  case,  where  a 
youth  of  seventeen,  with  a  bad  family  history,  suffered 
from  convulsive  movements  in  association  with  copro- 
lalia,  and  was  cured  of  the  latter  by  isolation.  Some 
would  even  recommend  the  removal  of  the  patient  to 
a  hospital  for  mental  disease.  Such  a  step,  however, 
is  rather  premature,  for  he  may  already  have  begun 
to  improve  where  he  happens  to  be,  and  it  is  not 
always  certain  that  a  sojourn  of  this  character  will  be 
beneficial. 

Before  isolation  is  resorted  to,  it  is  important  to 
familiarise  oneself  with  the  patient's  mode  of  life,  to 

1  WYEMANN,  "  Ueber  ein  Fall  von  Tic  de  Guinon,"  GSttinger  Dis- 
sertation, 1900. 


342          TICS  AND   THEIR    TREATMENT 

ascertain  whether  it  is  capable  of  modification  in 
accordance  with  one's  ideas  for  treatment,  and  to 
determine  the  exact  influence  of  his  environment  on 
him.  We  have  frequently  had  occasion  to  remark  how 
potent  is  this  environment  as  an  etiological  factor ; 
with  young  people,  in  particular,  negligence  on  the  part 
of  parent  or  guardian  places  the  child  in  jeopardy. 
To  combat  this  unfortunate  tendency  must  be  our  aim, 
as  soon  as  we  are  convinced  of  the  risk. 

Sometimes  it  is  sufficient  to  draw  the  attention  of 
the  parents  to  the  disastrous  consequences  of  indulgence 
or  indifference ;  but  we  shall  show  our  wisdom  in  not 
relying  too  much  on  promises,  however  sincere  and 
solemn.  These  parents  may  be  perfectly  honest  in 
their  protestations,  but  they  are  often  as  changeable 
and  weak  as  their  offspring,  and  lack  that  very  firmness 
and  perseverance  which  they  imagine  themselves  cap- 
able of  exhibiting.  Thus,  in  spite  of  their  undoubted 
intelligence  and  good  will,  their  efforts  at  control  are 
unsatisfactory,  and  under  such  circumstances  the  with- 
drawal of  the  patient  from  his  family  circle  is  urgently 
indicated. 

We  cannot  think,  nevertheless,  that  the  asylum  is 
the  ideal — there  is  risk  in  the  contiguity  of  other 
neuropaths  or  psychopaths;  and  while  the  value  of 
rigorous  isolation  consists  in  its  stimulating  and 
quickening  effect  on  the  patient's  self-control,  where- 
by the  day  of  his  return  to  ordinary  life  is 
hastened,  yet  it  too  frequently  happens  that  the  old 
temptations  are  as  powerful  as  of  yore,  and  that  the 
same  causes  which  operated  when  his  tics  first  made 
their  appearance  reawaken  vicious  tendencies  more  or 
less  imperfectly  masked. 

Most  subjects  learn  to  still  their  tic  during  the 
physician's  brief  visit ;  further,  most  achieve  a  similar 
result  while  they  remain  inmates  of  a  special  institution  ; 


TREATMENT  BY  RE-EDUCATION       343 

but  as  soon  as  they  find  themselves  in  their  old  quarters, 
so  soon  does  the  impulse  to  tic  dominate  them  again. 
In  fact,  their  victory  is  incomplete  ;  the  ground  they 
gain  is  not  held.  The  goal  to  strive  after  is  the 
repression  of  their  tic  under  all  conditions,  apart  from 
extraneous  intervention  and  influence.  Once  he  has 
been  instructed  in  the  methods  of  inhibition,  the  liqueur 
has  no  one  but  himself  to  fall  back  on  when  face  to 
face  with  the  allurements  of  his  daily  life. 

These  reserves  made,  it  is  clear  that  removal  of  the 
patient  from  his   environment  has  its  advantages,  but 
it  is  better  to  maintain  only  a  degree  of  isolation,  and 
to   allow  him  to  come  into  his  own  circle  from  time 
to  time,  under  a  wise  supervision.     The  ideal  measure 
would  be  to  consign  him  to  the  care  of   an  attentive 
and  devoted  teacher,  whose  superintendence  would  be 
permanent.     In  this  respect,  unfortunately,  all  that  we 
can   do   at    present    is    to   indicate   what  we   think   a 
desideratum,   for  while   well-to-do  families   may  have 
their  tutor,  we  do  not  know  of  any  one  who  has  held 
a  corresponding  office  as  an  instructor  of  children  with 
tic.     The   realisation  of  this   novel   proceeding   might 
present   genuine   difficulties   in   practice,  but  we  may 
hope  that   once  parents,   patients,  and   physicians  are 
acquainted  with  the  nature  of  tics  and  the  efficacy  of 
the  re-education  method,  many  prejudices  against  that 
fruitful  therapeutic  contrivance  will  vanish, 

PSYCHOTHERAPY 

Immobilisation  and  regulation  of  exercise  and  occu- 
pation do  not  constitute  the  whole  of  the  treatment ; 
they  form  merely  its  objective  side.  Psychotherapy  is 
another  factor,  of  capital  importance. 

In  the  words  of  Brissaud,  psychotherapy  is  an  ensemble  of  agencies 
calculated  to  demonstrate  to  the  patient  where  his  will  is  at  fault,  and  how 


344         TICS  AND   THEIR   TREATMENT 

to  exercise  to  the  best  advantage  what  of  it  is  left.  To  come  to 
particulars,  his  defect  lies  in  his  inability  to  check  a  cortical  caprice. 
These  are  not  rhetorical  unrealities,  nor  is  there  anything  mysterious 
about  the  method  ;  it  demands  no  special  competence  beyond  the  gentle 
and  encouraging  firmness  of  the  ideal  teacher.  The  physician  can 
constitute  himself  instructor  without  having  to  borrow  from  the  more  or 
less  occult  practices  of  hypnotic  suggestion.  In  fact,  we  must  make  it  clear 
to  the  patient  that  the  co-operation  of  the  latter  is  indispensable,  and  that 
it  is  his  will  which  is  to  come  into  action.  The  personal  influence  of  the 
teacher  will  be  exerted  in  sustaining  his  pupil's  efforts,  in  making  him  take 
note  of  the  progress  effected,  in  keeping  him  to  the  allotted  times  for 
exercise  and  drill. 

Thus,  and  thus  only,  is  psychotherapy  to  be  applied 
to  tic.  Lucid  and  sincere  explanations  and  kindly 
counsels  are  wanted,  not  ceremonies  and  mysterious 
paraphernalia.  Resoluteness,  patience,  clemency,  and 
good  sense  are  the  weapons  in  the  physician's  arma- 
mentarium ;  docility,  faith,  and  perseverance,  on  the 
patient's  part,  will  enable  him  to  emerge  victorious. 
As  soon  as  the  compact  is  made,  the  battle  against  bad 
habits,  where  there  is  neither  truce  nor  quarter,  com- 
mences in  earnest.  The  victim  to  tic  will  speedily 
unlearn  the  habit  of  perpetuating  bad  habits ;  he  will, 
in  addition,  learn  the  habit  of  not  contracting  bad 
habits.  In  this  way  a  double  benefit — physical  as  well 
as  moral — will  accrue. 

As  a  consequence,  psychotherapeutical  treatment 
directed  specially  to  the  subject's  mental  condition  is 
scarcely  necessary.  The  plans  adopted  to  inhibit 
inopportune  motor  manifestations  will  prove  of  value 
for  psychical  imperfections. 

Education  might  almost  be  considered  a  species  of 
prophylactic  treatment,  intended  to  obviate  the  possible 
development  of  tics.  Bourneville  has  verified  this; 
statement  in  his  experience  at  Bicetre: 

Gymnastic  exercises,  and  other  measures  directed  towards  the  develop- 
ment of  the  child's  faculties,  ought  to  be  conducted  with  kindness  and 


TREATMENT  BY  RE-EDUCATION       345 

gentleness,  and  by  the  aid  of  boundless  devotion  and  patience  the  methods 
of  the  authorities  are  bearing  unexpected  fruit  every  day.  We  are 
convinced  that  the  infrequency  of  tic  in  such  as  have  reached  puberty 
is  attributable  rather  to  the  zealous  application  of  a  sound  pedagogical 
method  than  to  anything  connected  with  the  age  and  physical  development 
of  the  child. 

Results  that  steadfast  and  patient  nurses  and  teachers 
are  obtaining  in  an  institution  like  Bicetre  may  surely 
be  obtained  by  the  physician  in  his  private  practice,  if 
the  parents  of  a  youthful  candidate  for  tic  would 
appreciate  the  importance  of  discipline  and  unite, 
intelligently  and  assiduously,  in  the  task  of  education. 
How  common  it  is  to  find  them  solicitous  only  of  loading 
his  tender  brain  with  learning,  instead  of  endeavouring, 
with  all  their  mind  and  heart,  to  restrain  deplorable 
bad  habits  that  may  one  day  blossom  into  tics,  to 
the  distress  of  all  concerned !  The  physician's  earliest 
duty  is  to  warn  the  parents  of  the  dangers  of  indiffer- 
ence, and  thereafter  to  install  himself  as  teacher,  if  the 
disease  should  manifest  itself  in  spite  of  his  precautions. 
He  has  no  choice  in  the  matter,  and  he  should  have 
the  frankness  to  say  so,  indicating  at  the  same  time  on 
what  his  convictions  rest.  He  need  have  no  fear  of 
damaging  his  professional  prestige  by  the  simplicity  of 
his  methods.  Let  him  not  promise  what  he  may  not  be 
able  to  perform ;  encouragement,  not  deception,  must 
be  his  watchword.  Along  these  lines  lies  his  duty 
as  a  physician  ;  there,  too,  will  he  find  that  his  treatment 
will  be  fraught  with  success. 


APPENDIX 

Les  tics  et  leur  traitement,  of  which  an  English  translation 
is  here  presented  to  the  medical  profession,  was  published  at 
the  close  of  the  year  1902.  In  it  our  knowledge  of  the  vexed 
subject  of  tics  and  spasms  has  been  summarised  and  reviewed, 
and  its  reception  in  France,  together  with  the  fact  of  its  having 
been  translated  into  German  without  delay,  prove  that  it  has 
been  regarded  as  the  standard  work  on  a  topic  the  importance 
of  which  is  being  daily  emphasised.  At  all  the  recent  Congresses 
on  the  Continent  the  tics  in  one  or  other  of  their  aspects  have 
provided  fruitful  matter  for  discussion,  whereas  in  England 
they  have  hitherto  been  greatly  neglected-  In  the  brief  space 
of  time  that  has  elapsed  since  the  book  was  produced  there  have 
been  many  and  varying  contributions  to  the  subject,  as  a  reference 
to  the  Bibliography  herewith  appended  will  show.  Without 
doubt  the  reawakening  of  interest  is  in  considerable  measure 
due  to  the  stimulus  provided  by  the  labours  of  MM.  Meige  and 
Feindel,  yet  it  cannot  be  maintained  that  they  have  said  the 
last  word.  In  order  that  English  readers  may  have  before  them 
the  latest  available  information  on  the  tics,  various  paragraphs 
from  Meige's  monograph  (1905)  have  been  incorporated,  as  has 
already  been  remarked  in  the  Prefatory  Note. 

It  is  desirable,  however,  to  indicate  briefly  certain  points 
on  which  opinion  is  still  divided,  points  on  which  the  results 
of  the  most  recent  observations  help  to  shed  some  light.  Probably 
it  has  not  escaped  the  reader's  attention  that  the  authors  have 
with  commendable  wisdom  refrained  from  dogmatising  on  some 
of  these,  although  they  are  always  able  to  give  reasons  for  their 
adherence  to  one  or  other  view.  But  in  one  respect  at  least 
the  attitude  which  they  have  adopted  has  been  unmistakable, 

346 


APPENDIX  347 

and  that  is  in  regard  to  the  fundamental  importance  of  agree- 
ment in  the  matter  of  terminology. 

The  amount  of  misconception  that  exists  about  what  constitutes 
a  tic  is  almost  beyond  credence  ;  indeed,  only  those  who  have  had 
occasion  to  examine  the  literature  can  have  any  adequate  idea 
of  it.  Discussions  at  neurological  and  other  societies  not  in- 
frequently reveal  how  vague  are  the  notions  of  many  who  must 
have  more  than  a  passing  acquaintance  with  the  disease  clinically. 
Now,  a  great  deal  of  this  misconception  would  disappear  if  the 
distinction  between  a  tic  and  a  spasm  elaborated  by  Brissaud 
were  adhered  to,  as  the  authors  so  strenuously  advocate.  It 
is  quite  unnecessary  to  insist  further  on  this  point,  but,  on  the 
other  hand,  it  is  only  fair  to  state  that  even  in  France  the  views 
of  Brissaud,  Meige,  and  Feindel  do  not  command  universal 
acceptance. 

M.  Cruchet,  of  Bordeaux,  to  whom  frequent  reference  is  made 
in  this  volume,  has  in  several  communications  on  tic  expressed 
himself  at  some  length,  and  some  of  these  have  made  their  appear- 
ance since  the  publication  of  Les  tics  et  leur  traitement.  According 
to  him,  the  original  meaning  of  the  word  "  tic  "  is  a  movement 
arising  in  a  "  bad  habit,"  and  there  would  never  have  been  any 
confusion  had  the  term  "  tic  douloureux  "  not  been  introduced. 
We  know  well  enough  the  exact  significance  of  this  term,  but 
its  use  led  to  the  adoption  of  the  cognate  term  "  tic  non- 
douloureux,"  and  in  the  latter  group  two  absolutely  different 
conditions  have  been  confused — viz.  true  tics,  and  spasms  in 
Brissaud's  sense.  The  difference  between  the  two  is  now  re- 
cognised everywhere  in  France ;  but  in  England  and  America, 
as  Risien  Russell  points  out  in  his  article  in  Clifford  Allbutt's 
System  of  Medicine,  tic  is  still  applied  to  such  conditions  as 
facial  spasm  and  the  involuntary  movements  of  trigeminal 
neuralgia,  whereas  it  should  be  reserved  for  what  we  usually 
call  "  habit  spasm  "  and  "  habit  chorea."  The  advantage  of 
the  word  "  tic  "  over  these  rather  cumbrous  terms  must  be  patent 
to  the  unbiassed  mind. 

It  is,  however,  in  his  persistent  affirmation  that  a  tic,  to  be 
a  tic,  must  be  clonic,  that  Cruchet  disagrees  with  the  tenets 
of  Meige  and  Feindel.  He  has  abandoned  the  use  of  the  term 
"  organic  tic "  in  favour  of  spasm ;  and  he  maintains  that 


348  APPENDIX 

"  tonic  tic  "  and  "  tic  of  attitude  "  should  give  place  to  "  habit 
attitude  "  and  "  convulsive  attitude,"  as  the  case  may  be.  His 
definition  of  tic  is  in  the  following  terms  : 

Tic  consists  in  the  execution — short,  abrupt,  sudden,  irre- 
sistible, involuntary,  inapposite,  and  repeated  at  irregular 
but  frequent  intervals — of  a  simple  isolated  or  complex 
movement,  which  represents  objectively  an  act  intended 
for  a  particular  purpose. 

Curiously  enough,  however  much  this  definition  emphasises 
the  clonic  element  in  tic,  Cruchet  makes  a  subdivision  into 
habit  tics  and  convulsive  tics,  of  which  the  former  "  are  exactly 
comparable  to  normal  movements,  except  that  they  are  invol- 
untary at  the  moment  of  their  execution,  are  performed  for 
no  reason  or  purpose,  and  their  frequency  is  unusual."  Their 
difference  from  convulsive  tics  is  merely  one  of  degree  ;  a  habit 
tic  may  become  a  convulsive  tic,  and  some  are  convulsive  from 
the  beginning.  A  habit  tic,  if  the  movement  be  a  slow  one,  is 
closely  allied  to  the  "  attitude  "  ;  and  it  is  not  always  practicable 
to  draw  a  distinction  between  them. 

Thus  Cruchet  himself  admits  that  the  clonic  element  in  tic 
may  be  minimal,  so  that  the  differences  between  him  and  our 
authors  are  by  no  means  so  insuperable  as  might  be  imagined. 
What  he  calls  a  habit  tic  is  equivalent  to  the  stereotyped  act 
of  the  others,  who  hold,  it  will  be  remembered,  that  the  move- 
ment of  tic  differs  from  the  normal  movement  not  merely  by 
being  involuntary,  irresistible,  inapposite,  and  so  on,  but  also  by 
being  exaggerated. 

It  cannot  be  denied  that  in  many  cases  of  tic  this  exaggera- 
tion of  the  normal  movement  is  anything  but  obvious ;  many 
conform  absolutely  to  the  definition  of  Meige  and  Feindel,  ex- 
cept that  the  movements  are  not  violent,  or  grotesque,  or  "  carica- 
tures." To  withhold  the  term  "  tic  "  on  this  account  would  be 
rather  unfortunate,  especially  since  no  standard  exists  where- 
by to  estimate  exaggeration.  Enough  has  been  said,  however, 
to  demonstrate  how  insignificant  are  the  discrepancies  between 
the  rival  definitions. 

Another  question  recently  raised  by  Cruchet  is  the  possibility 
of  the  persistence  of  tic  during  sleep. 

The  evidence  he  has  adduced  in  favour  of  this  has  now  been 


APPENDIX  349 

accepted,  as  far  as  tics  of  the  neck  are  concerned,  by  Meige. 
They  are  less  abrupt  and  less  frequent,  it  is  true  ;  otherwise, 
they  are  identical  with  the  movements  of  the  waking  hours. 
A  case  of  a  hiccoughing  tic  persisting  in  sleep  has  come  under 
my  own  observation  within  the  last  few  months.  Now,  it  is  not 
difficult  to  understand  that  a  movement  such  as  tic,  which  occurs 
during  the  conscious  state  in  spite  of  the  will  of  the  subject, 
may  arise  when  consciousness  is  diminished.  In  fact,  one 
wonders  why  they  are  not  more  frequently  remarked,  seeing 
that  they  are  habitual  movements,  and  habit  movements  are  by 
no  means  uncommon  in  sleep.  It  is  highly  probable,  of  course, 
that  the  observation  of  the  watcher  is  not  minute  enough,  but 
there  is  another  reason.  The  peculiarity  of  all,  or  almost  all,  of 
these  habitual  movements  in  sleep  is  that  they  are  rhythmical — 
we  may  instance  the  head  nodding  and  head  rolling  of  children  ; 
but  it  is  a  noteworthy  fact  that  they  are  often  regulated  by 
respiration.  When  it  is  recalled  how  respiratory  drill  is  eminently 
calculated  to  diminish  the  frequency  and  lessen  the  severity 
of  very  many  tics,  it  will  be  admitted  that  the  regularity  cf  the 
respiratory  movement  in  sleep  is  the  most  likely  explanation 
of  the  infrequency  of  tic  during  that  period. 

One  other  matter  may  be  shortly  alluded  to.  In  Cruchet's 
terminology,  a  tic  is  an  anomalous  gesture,  and  cannot  be  applied 
to  an  anomalous  attitude,  since  the  latter  is  tonic  rather  than 
clonic.  For  an  anomaly  of  attitude  he  suggests  the  use  of  the 
word  "  deformity."  Hence  "  habit  deformity  "  is  comparable  to 
habit  tic,  and  "  convulsive  deformity  "  to  convulsive  tic.  As 
a  habit  tic  may  develop  into  a  convulsive  tic,  so  a  habit  torticollis 
may  degenerate  into  a  convulsive  torticollis.  There  is  no  reason 
why  the  operation  of  habit  as  a  factor  should  not  effect  the  latter 
transformation  ex?ctly  as  it  does  the  former ;  and  as  habit  is  held 
to  be  a  psychical  phenomenon,  it  is  easy  to  conceive  why  the 
term  "  mental  torticollis  "  should  have  arisen,  and  been  so  widely 
accepted.  But  it  will  be  readily  understood  that  while  Cruchet 
affirms  that  no  mental  torticollis  can  ever  be  a  tic,  in  his  sense 
of  the  word,  this  is  due  solely  to  his  refusal  to  consider  any 
movement  which  is  tonic  as  partaking  of  the  nature  of  tic.  In 
all  other  respects,  the  description  which  he  gives  of  mental 
torticollis  shows  that  it  is  nought  else  than  a  tic  in  Meige's  sense. 


350  APPENDIX 

In  an  article  on  convulsive  torticollis  which  has  been  con- 
tributed by  Meige  to  the  Pratique  medico-chirurgicale  (1907) 
he  emphasises  afresh  the  distinction  between  torticollis-spasm 
and  torticollis -tic.  The  former  is  provoked  by  an  irritative 
lesion  in  the  motor  nerves  supplying  the  muscles  of  the  neck, 
or  in  their  nuclei  of  origin,  and  the  character  of  the  contractions 
("  contracture  fremissante  "  [Meige],  "  contractions  parcellaires," 
"  contractions  paradoxales  "  [Babinski])  in  a  definite  peripheral 
nerve  area  is  not  likely  to  be  mistaken.  In  other  cases  the 
objective  phenomena  distinctive  of  spasm  are  a  wanting  :  the 
characteristics  of  tic,  on  the  contrary,  are  conspicuously  present, 
and  among  these  cases,  where  psychical  disturbance  plays  a 
preponderant  role,  are  to  be  found  those  described  by  Brissaud 
as  mental  torticollis. 

It  is  to  be  noted  that  these  writers  alike  decry  the  surgical 
treatment  of  torticollis,  and  perhaps  not  without  good  reason. 
Nevertheless  the  method  must  not  be  condemned  on  theoretical 
grounds  merely,  and  it  is  permissible  to  believe  that  their  ex- 
perience may  have  been  unfortunate.  The  records  of  the  National 
Hospital  provide  many  instances  of  surgical  interference  in 
torticollis  and  allied  conditions  of  the  neck,  the  results  of  which 
make  one  hesitate  in  expressing  a  dogmatic  opinion.  It  is, 
however,  impossible  to  enlarge  further  on  the  subject  in  this 
place. 

S.  A.  K.  WILSON. 


BIBLIOGRAPHY 


[In  one  or  two  instances,  where  the  original  paper  has  been  in- 
accessible, its  title  is  reproduced  as  given  in  the  French  edition, 
but  in  brackets.  Through  the  kindness  of  M.  Cruchet,  of 
Bordeaux,  I  have  seen  the  proofs  of  his  new  volume  of  800 
pages  on  Les  torticolis  spasmodiques,  which  is  at  present 
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23 


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356  BIBLIOGRAPHY 

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358  BIBLIOGRAPHY 

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360  BIBLIOGRAPHY 

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FlERSINGER.      See    HUCHARD, 


362  BIBLIOGRAPHY 

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24 


370  BIBLIOGRAPHY 

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(Contains  many  interesting  references  to  the  early  literature. ) 


372  BIBLIOGRAPHY 

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(Many  references  to  the  literature.) 


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BIBLIOGRAPHY  373 

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(Thirty-four  references  to  the  subject.) 

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374  BIBLIOGRAPHY 

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(References  to  the  literature  on  the  psychical  side  of   the 
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See  CLAUS. 

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376  BIBLIOGRAPHY 

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(One  hundred  and  sixteen  references  to  the  literature  of 
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SCHUSTER,  "  Tonische  und  klonische  Krampf  des  ganzen  rechten 

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(Eighty -eight  references  to  the  literature,  chiefly  Italian.) 

SICURIANI,  "  Contributo  allo  studio  del  tonomioclono,"  Riforma 

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BIBLIOGRAPHY  377 

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International    Medical    Congress,    Rome,     1894,    Section    of 

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SOLGER.     See  STEYERTHAL. 
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P-  31- 

(Many  interesting  references  to  ancient  writers.) 
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P-  1754- 
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TAMBURINI,  "  Fisiopatologia  e  cura  del  tic,"  Rivista  sperimentale 
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378  BIBLIOGRAPHY 

TANON.  See  BRISSAUD. 
TESSIER.  See  MASSARY. 
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difiuso,"  Giornale  di  neuropatologia,  1886,  Nos.  3  and  4. 
THOMAS,   "  Contribution  a  1'ctude  de  la  maladie  des  tics  chez 

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THORNTON,  "  Some  Curious  Facts  concerning  '  the  Jumpers,'  " 

New  York  Medical  Record,  1885,  p.  713. 
TISSIE,  "  Tic  oculaire  et  facial  droit  accompagne  de  toux  spas- 

modique,  traite  et  gueri  par  la  gymnastique  medicale  respira- 

toire,"  Journal  de  medccine  de  Bordeaux,  July  9,  1899. 

See  PITRES. 

TOKARSKI,  "  Maladie  des  Tics  convulsifs,"  Neurologisches  Central- 

blatt,  November  i,  1890,  p.  662  (reference). 
TOULIERES.     See  CABANNES. 
TOURETTE    (GiLLES    DE    LA),    "  Jumping ;    latah ;     myriachit," 

Archives  de  neurologic,  1884,  p.  68. 
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de  1'incoordination  motrice   accompagnee  d'echolalie  et  de 

coprolalie,"  Archives  de  neurologic,  1885,  p.  19. 

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Salpetriere,  1889,  p.  182. 
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TOURETTE  (GILLES  DE  LA)  AND  DAMAIN,  "  Un  danseur  monomane," 
Progres  medical,  January  14,  1893. 

UCHERMANN,  "  Ein  Fall  von  alternirenden,  rhythmischen,  und 
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UNVERRICHT,  "  Ueber  familiare  Myoclonus,"  Deutsche  Zeitschri/t 
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VALOBRA,    "  Policlono   infettivo ;    contributo  allo  studio   delle 

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tcheques  a  Prague,  1901. 


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INDEX    OF    NAMES 


A.,  166 

Achard,  291 
Aime,  212 
Allocco  (d'),  286 
Amussat,  169 
Andre,  26 
Appleyard,  308 
Atkins,  308 
Axenfeld,  26,  246,  299 

B.,  131,  134 

B.  (Seglas),  265 

Babinski,  135,  136,  137,  152,  276 

Bain,  60 

Ball,  216 

Ballance,  309 

Ballet,  76,  152,  335,  337 

Bamberger,  196 

Beard,  196,  250 

Bechterew,  143,  198,  288 

Bergeron,  251,  284 

Bernhardt,  98,  145 

Biaggi,  209 

Billot,  162 

Blache,  99,  315 

Blocq,  55,  64 

Bompaire,  169,  175,  317 

Bonnier,  127 

Bouchut,  246 

Boumeville,  27,  127,  257,  316,  344 

Brener,  267 

Bresler,  92,  267 

Briand,  170,  182,  207 

Brif.,  i49 

Briquet,  246 

Brissaud,  27,  37,  40,  55,  59,  67, 
68,  74,  100,  108,  111,  119,  123, 
124,  139,  166,  167,  172,  174, 
177,  181,  210,  218,  220,  228, 
229,  234,  238,  268,  271,  281, 
295,  296,  312,  316,  319,  324, 
328,  331,  333,  343 

Brodie,  266 

Bruandet,  275 


Buck  (de),  128,  169 
Buss,  113 

C.  (Noir),  258 

Cadiot,  112 

Cahen,  264 

Campbell,  307 

Cantilena,  218 

Cestan,  153 

Chabbert,  225,  247 

Charcot,  27,  34,  39,  40,  48,  58, 
60,  62,  74,  75,  80,  87,  98,  108, 
116,  125,  167,  207,  227,  246, 
251,  281,  300,  304 

Chatin,  162,  240 

Chauffard,  278 

Chervin,  325 

Chipault,  111,  114,  310 

Chomel,  94 

Clans,   143 

Cohn,  148 

Collier,  307 

Colombat,  303 

Constant,  101 

Corning,  312 

Coudray,  308 

Crouzon,  151 

Crochet,  25,  32,  39,  65,  68,  101, 
102,  113,  115,  116,  122,  199, 
220,  250,  257,  295,  326J 

D.,  106 
Dal  wig,  311 
Debrou,  110,  114 
Dej6rine,  171 
Delasiauve,  99 
Demosthenes,  303 
Derevoge,  209 
Descroizilles,  333 
Desterac,  136,  276,  277 
Dide,  252 
Dornbluth,  301 
Dubini,  284 
Dubois,  53,  87,  328 


380 


INDEX   OF  NAMES 


Duchenne,  114,  167,  177,  178 
Dufour,  296 
Dupre,  54,  56,  86 
Durand,  335 

E.,  186 

E.  (Noir),  289 
Edel,  204 
Ehret,  193 
Eliot,  308 
Erb,  32 
Esquirol,  257 
Etmuller,  33 

F.,  86,  150 

Faure,  312 

Fechner,  338 

Feindel,  121,  123,  166,  169,  173, 

185,  238,  239,  317,  321,  333 
Fer6,  111,  170,  234,  244,  253,  254, 

338 

Feron,  305 
Ferrand,  32 
Ferrier,  111 
Flatau,  100 
Flechsig,  301 
Fornaca,  276 
Fournier,  238 
Fraenkel,  313 
Francois,  26 
Francotte,  162 
Frenkel,  322 
Freud,  267 

Friedreich,  251,  285,  287 
Fur  (le),  114 

G.,  86,  98,  148,  155,  166 

Gardner,  307,  308 

Gaupp,  242 

Gehuchten  (van),  178,  291 

Geyer,  213 

Gilbert,  112 

Giles,  307 

Gintrac,  99 

Gonzales,  116,  253 

Gowers,  98,  257,  281 

Graefe  (von),  147 

Graff,  170 

Grasset,  27,  60,  65,  66,  67,  68,  84, 
91,  93,  106,  132,  169,  173,  175, 
177,  214,  239,  242,  291,  301, 
302 

Graves,  26 

Guibert,  169 

Guillain,  181,  277 

Guinon,  27,  39,  45,  46,  47,  51,  56, 


58,  63,  80,  87,  90,  102,  104,  119, 
156,    164,    189,    195,    196,    197, 
206,  215,  216,  219,  224,  300 
Gunn,  323 

Hajos,  288 
Hall,  33 
Hallion,  270 
Hammond,  196 
Hartenberg,  198,  302,  322 
Haskowec,  83 
Hasslauer,  211 
Heldenbergh,  287 
Helfreich,  323 
Henoch,  251 
Hermann,  286 
Hitzig,  114 
Holland,  216 
Hoppe-Seyler,  201 
Huntington,  281 
Huyghe,  314 

Ibsen,  213 
Innfeld,  228 
Itard,  76,  303 

J.,  52,  54,  76,  78,  81,  84,  98,  100, 
105,  121,  131,  139,  155,  160, 
183,  185,  186,  221,  240,  243, 
330,  340 

J.  (Noir),  289 

Jaccoud,  34 

Jacoby,  193 

Jancowicz,  287 

Janet,  64,  65,  86,  121,  162,  169, 
172,  173,  176,  183,  187,  193, 
195,  199,  223,  238,  240,  241, 
248,  305,  306,  316,  317,  326 

Janke,  210 

Joffroy,  269,  296 

Jolly,  315 

Jourdin,  26,  33 

K.,  239 

Kaiser,  289 

Keen,  309 

Kennedy,  312 

Kny,  288 

Kocher,  162,  309,  310 

Kopczynski,  212,  228 

Koster,  227,  328 

L.,  58,  79,  105,  126,  135,  136,  178, 
190,  233,  255,  273,  274,  292, 
332,  340 

L.  (Noir),  258 


382 


INDEX  OF  NAMES 


Labbe,  291 

Lam.,  84 

Lange,  159 

Langlois,  39 

Lannois,  170,  316 

Legenmann,  170 

Legouest,  169 

Legrain,  28 

Lemoine,  286 

Lentz,  175 

Lerch,  150,  198 

Letulle,  27,  46,  47,  57,  63,  64,  91, 

99,  158,  204,  208,  213,  264,  291, 

315 

Leubo,  159 
Lewin,  38 
Linz,  310 

Littre,  36,  45,  56,  102,  122 
Luzenberger,  256 

M.,  78,  98,  100,  134,  145,  186 

Madet,  327 

Magnan,  27,  28,  30,  76,  108,  227 

Malm,  253 

Mannini,  252 

Marechal,  177,  306 

Marie  (A.),  266 

(P.),  161,  153,  165,  181,  273, 

277 

Marina,  *290 
Martin,  175,  331 
Massaro,  157 
Mayer,  274 
Mayor,  307 
Meige,    124,    140,    169,    172,    185, 

238,  239,  261,  269,  317,  335 
Meirowitz,  145 
Mills,  291 
Mitchell,  281 
Molifere,  100 
Monakow  (von),  39 
Montaigne,  44 
Morel,  28,  296 
Morin,  303 

Morvan,  251,  284,  285 
Moutard-Martin,  325 
Muratow,  39 
Murri,  116 

N.,  134,  173,  180,  185,  190,  239 

N.  (Noir),  257 

Napoleon,  101 

Nieden,  171 

Niemeyer,  26 

Nogues,  154,  169,  175,  203,  239 

Noir,  27,  53,  65,  90,  93,  98,  109, 


127,    148,   217,   218,   222,  227, 

267,  259,  284,  291 
Nonne,  283 
Nothnagel,  112 
Nove-Josserand,  310 

O.,  1  et  aeq.,  62,  59,  76,  79,  121, 
134,  135,  140,  144,  145,  155, 
160,  183,  186,  189,  193,  222, 
236,  243,  328,  329,  330,  340 

O'Brien,  103,  196 

Oddo,  89,  195,  279,  296,  324 

Oettinger,  328 

Olivier,  208,  325 

Onanoff,  55,  64 

Oppenheim,  32,  98,  112,  139,  144, 
164,  169,  170,  175,  197,  204, 
256,  276,  294,  302,  311,  312, 
322,  328 

Oppolzer,  114 

Oxen,  308 

P.,  134,  139,  180,  186,  190 

Parinaud,  147,  152 

Patella,  117 

Patry,  230 

Pauly,  308,  309 

Pearce-Gould,  307 

Peter  the  Great,  100,  161 

Pick,  212 

Piedagnel,  99 

Pinel,  257 

Pitres,  27,  32,  33,   199,  200,  201, 

215,  216,  221,  246,  247,  325 
Ponsgen,  201 
Popoff,  310 
Pujol,  26,  299 

Quorvain  (de),  310 

R.,  78,  119,  126,  134,  144,  150,  323 

R.  (Noir),  257 

Ramisiray,  196 

Ranschburg,  159 

Rauzier,  301,  302 

Raymond,  30,  121,  153,  162,  169, 
172,  173,  176,  187,  193,  195, 
199,  233,  240,  241,  248,  261, 
305,  306,  326 

Redard,  177 

Regis,  83,  138 

Renterghem  (van),  305 

Ribot,  65 

Richet,  39 

Ricklin,  284 

Riviere,  201 


OP  NAMES 


383 


Roger,  112 

Romberg,  26,  114,  145,  171 

Ros.,  259 

Rossi,  116,  253 

Rossolimo,  198 

Roth,  83 

Rudler,  94 

Russell  (Risien),  309 

S.,  79,  88,  104,  125,  126,  134,  139, 

140,    141,    155,   162,    180,    190, 

222,  237 
Sabrazes,  201 
Saenger,  204 
Saint-Simon,  100 
Sano,  143 
Sarbo  (von),  159 
Saury,  28 
Sauvages,  33 
Schapiro,  204 
Scheiber,  125 
Scherb,  248 

Schultze,  111,  114,  288 
Schupfer,  253,  287 
Sciamanna,  227 
Seeligmiiller,  146 
Seglas,  57,  63,  83,  173,  175,  188, 

197,    199,   201,   202,   214,    215, 

220,  265,  296,  319 
Sgobbo,  169,  173,  175,  237 
Siemerling,  197 
Sinkler,  281 

Sirol,  154,  169,  175,  203,  239 
Smith,  309 
Sollier,  257 
Soupault,  291 
Souques,  169,  172,  278 
Southam,  307 
Spencer,  60 


Stewens,  312 
Striimpell,  159 
Sydenham,  279 

T.,  185,  186,  295 

Thiem,  193 

Thomson,  288 

Tichoff,  311 

Tissi6,  99,  103,  129,  205,  223,  326 

Tordeus,  284 

Tourette,   27,   45,    196,   216,   219, 

223,    224,    229,   232,   233,    293, 

299,  300 
Troisier,  32,  299 
Trousseau,  26,  58,  108,  118,  167, 

251,  298,  315 

Uchermann,  212 

Valleix,  26,  33,  147 
Verga,  219 
Verlaine,  314 
Vigny  (do),  107 
Virchow,  41 
Vlavianos,  305 
Vogt,  335 

W.,  186 

Walton,  171,  311 
Weber,  338 
Welterstrand,  305 
Widal,  32 
Wille,  92 

WiUis,  31,  33,  34,  167 
Wolff,  193 
Wutzer,  303 
Wyemann,  341 

X.,  79,  231 


INDEX    OF    SUBJECTS 


Aerophagia,  199  et  aeq. 
Affirmation  tics,  163 
Antagonistic    gestures,    168,     236 

i'l  aeq. 

Aphonia,  211 
Arithmomania,  87 
Athetosis,  288 
Attacks,  128 
Attitude  tics,  63,  122 
Auditory  tics,  145 
Automatic  movements,  41,  43, 259 

Beating  tics,  185 
Beggar's  tic,  248 
Biting  tics,  11,  159 
Blepharospasm,  147 
Blinking  tics,  3,  148,  149 
Blowing  tics,  303 

Catatonic  aptitudes,    124 
Cheilophagia,  160 
Chin  tics,  167 
Chorea,  Dubini's,  284 

electric,  252,  284 

fibrillary,  251,  284,  285 

gravidarum,  283 

H6noch-Bergeron's,  251,  284 

Huntington's,  281 

hysterical,  282 

of  degenerates,  230 

paralytic,  285 

polymorphous,  230 

rhythmical,  283 

Sydenham's,    279 

—  variable,  119,  228  et  aeq.,  281 
Clonic  tic,  118 
Colporteur  tic,  106,  173 
Complications  of  tic,  242  et  aeq. 
Consciousness  and  tic,  63 
Convulsion,  39 
Convulsive  tic,  31 

clonic,  3 1 

tonic,  31,  63 

Co-ordination  and  tic,  45,  126 


Coprolalia,  13,  219  et  aeq.,  258 
Coughing  tics,  203 
Curability  of  tic,  298  et  aeq. 

Definition  of  tic,  260 
Degeneration,  28,  29 
Diagnosis,  264  et  aeq. 
Diaphragmatic  tics,  205 
Diet,  302 

Ear  tics,  145 

Echokinesia,  103,  124,  217 
Echolalia,  216  et  aeq. 
Echomimia,  124 
Echopraxia,  124 
Electrical  reactions,  138 
Electrolepsy,  284 
Electrotherapy,  303 
Epilepsy  and  tic,  251  et  aeq. 
Eructation  tics,  196 
Etiology  of  tic,  96  et  aeq. 
Etymology  of  tic,  25 
Evolution  of  tic,  221  et  aeq. 
Expectoration  tics,  197 
Eye  tics,  146,  151 
Eyeball  tics,  150,  323 
Eyelid  tics,  146,  322 

Facial  spasm,  110,  111,  143,  268, 
210  et  aeq.,  312 

tic,  143,  220  et  aeq.,  312,  323 

Fixed  tics,  130 
Folie  du  pourquoi,  87 
Function,  70 

Genesis  of  tic,  48  et  aeq. 
Geniospasm,  157 

Habit,  56 
Heredity,  98 
Hiccoughing  tics,  203 
Hydrotherapy,  302 
Hygiene,  302 
Hysteria,  246  et  aeq.,  282 


384 


INDEX  OF  SUBJECTS 


385 


Idiocy,  256 

Imitation,  2,  101 

Immobilisation     of     movements, 

317 

Impulsive  tics,  disease  of,  227 
Insanity,  256 
Isolation,  341 

Jacksonian  epilepsy,  38,  251,  253 
Jaw  tics,  159 

Krouomania,  258 

Laryngospasm,   212 
Latah,  103 
Leaping  tics,   193 
Licking  tics,  157 
Lip  tics,  155 

Massage,  303 
Mastication  tics,  159 
Mechanotherapy,  303 
Medicinal  treatment,  301 
Mental  condition  of  the  subjects 

of  tic,  74  et  aeq. 
infantilism,   76  et  aeq.,    133, 

171 

tic,  94 

torticollis,     121,      137,      167 

et  seq.,  257,  267,  307,  313,  323, 

324,  331,  333 

trismus,  121,  161  et  seq.,  240 


Mimicry,  60,   103 

tics,  143 

Mirror  drill,  335  et  aeq. 

writing,  335  et  aeq. 

Monoclonus,  287 
Motor  reaction,  41 

classification   of,   44 

localisation  of,  130 

study  of,  118 

Movements     of     immobilisation; 

317 

Mutism,  211 
Myoclonus,  30,  116,  252  et  aeq.,  285 

et  aeq.,  288 
Myokymia,  288 
Myospasm,  290 
Myospasmia  spinalis,  288 
Myotonia,  288 

Neck  tics,  5,  163,  323 
Negation  tics,  163 
Neurasthenia,  250  et  aeq. 
Nictitation  tics,  146 


Nodding  tics,  163 
Nose  tics,  3,  154 

Obsessions,  82  et  aeq. 

Occupation  neuroses,  70,  72,  159, 

291  et  aeq. 
Onomatomania,  87 
Onychophagia,    161 
Orthopaedic  treatment,  314 

Palpebral  tics,  147 
Paramyoclonus     multiplex,     252, 

285 

Para-tics,  6,  7 
Pathogeny  of  tic,  36  et  aeq. 
Pathological  anatomy,  108  et  aeq. 
Phobias,  20,  88 
Polyclonus,    116,    117,    252,    256,    » 

287 

Polygon,  65 
Procollis,  177 

Professional  acts,  69,  71,  291 
Prognosis,  293  et  aeq. 
Psychical  tic,  29,  94 
Psychomental  tic,  68,  94,  250 
Psychotherapy,  343 

Re-education,  315  et  aeq. 
Pveflexes,  15,  134 
Relapses,  332 
Respiration  tics,  203 
Respiratory  drill,  325  et  aeq. 
Rest,  340 
Retrocollis,  177 
Rhinchospasm,  204 
Rhythm,  70,  127 
Rhythmic  tics,  127 

Salaam  tic,  164 
Salutation  tics,  163 
Scratching  tics,   186 
Secretory  affections,    138 
Sensation,  affections  of,  140 
Shoulder  tics,  9,  183 
Sniffing  tics,  154,  203 
Snoring  tics,  203 
.Sobbing  tics,  203 
Spasm,  definition  of,  36 
Spasms  and  tics,  36   et  aeq.,  267 

et  aeq. 

Spasmus  nutans,  127,  164 
Speech,  tics  of,  206  et  aeq.,  324 
Sphincter  tics,  140 
Stammering,    208    et    aeq.,     324, 

325 
Starting  tics,  291 

25 


INDEX  OF  SUBJECTS 


Stereotyped    acts,   57,    122,    188, 

264  et  aeq. 
Striking  tics,  185 
Sucking  tics,  155 
Swallowing  tics,   106 

Thomson's  disease,  288 
Tic  and  function,  68 

idea,  59 

will,  55 

writing,  187,  190 

Tic  douloureux,  112,  275 
Tic  non  douloureux,  110 
Tics  of  idea,  94 

idiots,  53,  256 

wind  sucking,  196 

Tongue  tics,  157 


Tonic  tic,  118,  121 

Torticollis  tic  and  spasm,  136,  137, 

275  et  aeq.,  307 
Tossing  tics,  163,  323 
Tourette's  disease,   92,   223,   228. 

251,  258/296 
Treatment,  298  et  aeq. 
Tremors,  290 
Trunk  tics,  182 

Variable  tics,  130 
Visceral  instability,  139 
Vision  tics,  146 
Vomiting  tics,  196 

Whistling  tics,  203 

Writers'  cramp,  69,  72,  192,  292 


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